Dr. Angela Poppe Ries and Dr. Phil Nivatpumin, University of Maryland Upper Chesapeake Medical Center
Health care is constantly changing – and for good reason. Technological advances, new discoveries in disease treatment, cutting edge, game-changing research, and institutional changes as a result of the Affordable Care Act all keep hospitals in a state of continuous change. Two innovative physicians at University of Maryland Upper Chesapeake Medical Center (UM UCMC), who represent the fresh face of health care embrace, even welcome, these ongoing changes and look to change health care for the better for their patients and the community as a whole.
Angela Poppe Ries, M.D., director for palliative care services and president of the medical staff who is board certified in palliative and internal medicine, and Phil Nivatpumin, M.D., medical director of the Kaufman Cancer Center and population health who is board certified in internal medicine, hematology and oncology, aim to better educate patients on their conditions and empower them to take control of their health care.
Dr. Poppe Ries says when she meets with a high-risk patient she explores how to “manage an individual’s care in a way that they can understand and participate in. I’ll first ask, ‘What do you understand about your illness and your health?’ I think some patients are unaware of what we assume to be a known entity. For example, a diabetic patient may say, ‘Well, my sugar just gets a little off.’ Well, what does that mean to you and how do you manage it? They may not fully understand how that affects day-to-day life and how it affects them short-term and long-term.”
She adds that when there is a mismatch with what the patient understands about their condition and what the medical system around them knows, there tends to be care that is either redundant or lacking, which causes dissatisfaction from the providers, patient and family because no one understands what the overall game plan is.
“So let’s engage the patient in their own care in a very different way by having them be mindful of what they are feeling and experiencing,” Dr. Poppe Ries continues. “For example, we had a patient who regularly complained of chest pain. So I would ask, ‘Explain that to me … what are you feeling?’ They may not actually have chest pain, but they will say, ‘I’m a little anxious about this, or I need to know how to get this next medication.’ All that combined is causing a somatic symptom, so we determine that the pain is not cardiac related but what we don’t always do as doctors is to say, ‘OK, you are still sensing something and how do we change that?’ For a lot of people managing their health does not mean a trip to the ER for an expensive MRI. It could be a change of sleep or diet or access to health care insurance.”
Dr. Nivatpumin, who enjoys martial arts, yoga and clean eating, stresses the importance of lifestyle modifications as a means of psychological, physical and spiritual healing. He notes that about 50 percent of cancer cases are related to lifestyle, such as diet and tobacco use, and when it comes to Type 2 diabetes, the numbers are close to 70 percent. Instead of simply telling patients to stop smoking or eat better, Dr. Nivatpumin takes the time to explore what is driving the behavior that is affecting their health.
Many times, he says, it is related to the patient’s upbringing. “Did you suffer from emotional, psychological, sexual or physical abuse as a child? Did you have a toxic environment as a child, adult or even in the womb? Part of personalized care is listening to each patient … where do you live, what type of environment did you grow up in, what is your family like? Modern medicine in America has gotten away from this because we were so busy trying to give you the most high-tech treatment, but maybe you need low-tech treatment like simply someone listening to you.”
Dr. Poppe Ries adds that while traditional lifestyle modifications such as eating well and exercising are important, “There is literature on how being more aware of your body and being more open, mindful and thoughtful actually helps your overall physical and psychological health in a way that was appreciated 100 years ago but when medicine became more technological, we lost that ability to fully appreciate this.”
‘Physicians Not the Only Answer’
Both Dr. Poppe Ries and Dr. Nivatpumin point to the need for hospitals to form partnerships beyond their own medical systems and team up with government agencies – i.e., state and county health departments, Department of Aging – as well as local non-profits, an innovative approach brought on in part by economic incentives from the Affordable Care Act.
“Maybe physicians are not the only answer in this new paradigm,” says Dr. Poppe Ries. “If I have cancer, yes, I want Dr. Nivatpumin to look at my genetic sequence and determine what mutation I have and the hormone receptor status. But if I am struggling with coping, how I pay for a treatment, or whether I should continue to work, maybe what I really need is a navigator who helps me transition through my care. We both feel strongly that you need a team, and in a high-risk clinic, the social worker or nurse are driving the path because they are the ones spending one or two hours with the patient. We’ve gotten away from that due to the amount of technological information that must be absorbed in medical school, internships and fellowships, but we now need to use other services to get patients what they need.”
According to a 2009 study by the Commonwealth Fund, the United States spends nearly $8,000 per person per year for health care services – more than 12 other industrialized countries – and yet this investment does not necessarily result in superior care. Dr. Nivatpumin says it’s important to look at controlling costs and measuring values.
“What I have learned about population health is that economics and incentives drive a lot of behavior, and the prior system of ‘fee-for-service’ drove a lot of individual, episodic and high-tech care with the goal of the more patients I can see and give more treatment to, the more I can charge,” he says. He adds that the fee-for-service model would also disincentivize collaboration between health care professionals since the time spent would take away from the ability to see more patients. “The Affordable Care Act has dramatically changed that – there are new incentives to measure quality and to utilize and pay for a home health aid to visit a patient, for example. It’s always been the moral thing to do, but you have to also make it economically viable.”
Dr. Poppe Ries recalls a young patient in her 20s who came to the ER three or four times with complications from Type 1 diabetes, racking up bills in the tens of thousands.
“She was a single mom with a low-wage job who had to drop her child off at daycare and then get to work, so she didn’t always remember to take her insulin. She would come in and be labeled as non-compliant, but she was really overwhelmed. A nurse navigator discovered a smartphone app that reminded her to test her sugar, and the nurse would then follow up with her once a day to see how she was doing. The patient has not been to the ICU in two months, but if not for this simple solution, she would be discharged again and again with no follow-up – how does that benefit her or our health care system?”
In the past, hospitals would benefit financially each time this patient would return, but now they are incentivized to spend time with her and help her in non-medical ways.
“I understand the fear of so-called socialized medicine or rationed care, but when you look at a case like hers, I find it hard to believe that we are not moving in the right direction,” says Dr. Poppe Ries. “When I hear people say, ‘I don’t want people freeloading off the system,’ I don’t think they know that with every uninsured person who comes into a hospital, we are all paying for it through increased premiums. If we can create a structure that maintains costs and gets people the right care, at the right place, at the right time, it actually saves money and it’s the right thing to do.”
Identifying High-Risk Cases
One of the innovative ways UM UCMC tackles health care costs is through its new Comprehensive CARE Center, a pilot outpatient program that started in January at its Bel Air campus. The objective of this model of care is to provide more personalized and navigational care for people in the community struggling with difficult conditions. The CARE Center, where Dr. Poppe Ries serves as medical director, targets those patients who utilize a lot of care but may be better served through resources outside the hospital and actually need someone to help them navigate the health care system. Dr. Poppe Ries recalls a man who was basically homeless without access to reliable heat, quality food or insurance who would call 911 three or four times a week as it was the only safety net he knew, and he would get an MRI, stress tests and other unnecessary and costly tests.
“We programmed the phone number for the CARE Center in his phone. Then, our social worker got him food stamps, and he got qualified for disability, which he didn’t know he qualified for, and now he’s on a wait list to get into a group home, which his disability will cover,” says Dr. Poppe Ries. She adds that if this individual – with no Internet access and in essence a sixth-grade education level – was simply handed a 20-page form to apply for disability, he couldn’t complete it. “Instead, we had him come into the CARE Center, and sit with us as we filled out the application together to make him part of the process. Since then, he’s had two ER visits in two months,” says Dr. Poppe Ries.
“We are trying to get people to a point of independence by intervening in the beginning with intensive care but eventually transition to teaching them life skills and health literacy, how to get a job, and then hopefully discharge them down the road. I believe that caring without goals or boundaries is basically just enablement,” adds Dr. Nivatpumin.
An unenviable aspect of both Dr. Poppe Ries and Dr. Nivatpumin’s jobs is to help patients also navigate the last years of their lives by helping them with issues such as an advanced directive, but more importantly, asking them what is most important to them, what their goals are and how can their treatment coincide with those goals.
“Whether I am seeing someone with a terminal illness or not, I try to encourage them to have these discussions even if they are years down the road,” says Dr. Poppe Ries. “Most people have their funeral planned out with what song they want played and how they want to be remembered, but what about those five years or five months of living – how are you going to live that time in a way that is consistent with your goals and your values?” I95
Right Patient, Right Care, Right Place
The new Comprehensive CARE Center at the University of Maryland Upper Chesapeake Medical Center is an outpatient health center dedicated to helping patients navigate the right care in the right setting. Its focus is to provide continuity of care by facilitating and coordinating communication between the health care team, the patient and their family.
Who is the “Right Patient” for the Comprehensive CARE Center?
• Patients who have no primary care provider and are frequent users of emergency rooms to receive care
What are the services provided?
University of Maryland Upper Chesapeake Medical Center