Case Study:

Teamwork in Managed Care

Case 1: Mrs. Fraga
(Case developed by Ann Schneider, L.M.S.W.)

Mrs. Fraga is an 82-year-old Hispanic widow who has lived in a nursing home for four years. She is enrolled in a Medicare HMO. Her primary care physician works for a medical group that received capitated payments from a Medicare HMO for professional services. The physician’s group works closely with one hospital system, which is receiving capitated payments for in-patient care. The medical group and the hospital system have "shared risk pool", that is divided at the end of the year based on the amount and frequency of hospitalization during the contract year.

Mrs. Fraga has moderate Alzheimer’s disease, hypertension, and coronary artery disease. She developed pneumonia, and was put on oral antibiotics. The medication upset her stomach and she stopped eating and drinking. She became dehydrated, listless and non-responsive. The nursing home was alarmed at her condition, called 911 and sent her to the hospital. At the hospital she was hydrated and put on IV antibiotics. After 24 hours she was responsive to conversation and showing strong signs of recovery. She spent three days in the hospital at a cost of $5,000.

Case 2: The "Good But Not Perfect" Case
(Epstein & Aldredge, 2000 (pp 100-101)

The following scenario profiles a team meeting called by Frank Pearman, vice president for managed care contracts, after several confrontations with the team members over changing protocols. Reenie (the social worker), Dr. Oliviero (the neurologist), Carolyn (the head nurse), and Josh (the physical therapist) are the members of the interdisciplinary team.

"Ladies and gentleman, I called this meeting today because, frankly, we need to talk." Frank Pearman kicked off the team meeting in the administrative suite. Carolyn, Reenie, and Josh glanced quickly at each other, then turned to Dr. Oliviero in almost complete unison.

"More than that, my good man, " Dr. Oliviero did not disappoint his team. "You need to listen."

"That may be. Wouldn't hurt any of us to listen to each other," Frank countered. "But you all are not in a place to hear. We have a number of issues on the table that must be addressed, like it or not. You as a team have to figure out how to respond to the concerns at hand."

"We, as a team, sir, have functioned quite well for several years. Hundreds of patients have benefited from the expertise of this team. Without your help, certainly, and definitely without your condescension." Dr. Oliviero was not going to let this young whippersnapper put anything by him.

"You are absolutely right, good doctor. You have helped thousands of people, in fact. I agree with you one hundred percent." The team members sat silently, waiting for the catch. "What I must challenge you to do now, is figure out how you will continue to help people in this changing environment."

"We'll help them the way we have always helped them," Reenie ventured tentatively into the discussion, relying on one of her favorite sayings. "If it ain't broke, don't . . . ."

"Yes, I know, "don't fix it, '" Frank finished the sentence for her. "And I agree with that, Reenie. Sound management concept not to tinker with something that is working. However, what you all are missing is that something is broken. Health care has changed, and you all, individually and as a team, have not. It's broken, Reenie. You must figure out how to fix it."

"How can you say it is broken?" Carolyn was indignant. "What evidence do you have that we need to change anything? Our patients are going home functionally improved and happy with our care."

"Your patients are exhausting what little bit of coverage they have for rehabilitation in their stay on your program. And they are going home ignorant to the fact that they could have been discharged earlier with an outpatient program that would have conserved their benefits and gotten them to the same level physically. Some of them are getting billed for equipment that is no longer covered under their plans but none of you have bothered to check that. The hospital lost $30,000 last reporting period on your unit alone in spite of a full census. That is money that could have been used to hire additional staff had it not been squandered by your inattention to the changing environment."