Building A Better System

When it comes to preventing and treating chronic illness, there are a lot of variables in play. There are, of course, genetics, environment, lifestyle and medications. Then there is the health care system. How patients gain access to and interact with the system of care is the linchpin, according to Michael Pignone, M.D., M.P.H.

As professor of medicine and division chief for general medicine and clinical epidemiology at UNC School of Medicine, he interacts with the system on many levels each week.

He researches ways to improve the system as director of the UNC Center for Excellence in Chronic Illness Care, as director of Medical Practice and Prevention Research at the Sheps Center for Health Services Research, as a member of UNC Lineberger Comprehensive Cancer Center and with the UNC Center for Health Promotion and Disease Prevention. His newest responsibility is leading the Literacy and Numeracy Core of the UNC Center for Diabetes Translation Research to Reduce Health Disparities (CDTR). In between all that, he regularly sees patients in clinic so he knows firsthand what works and what doesn’t work for them.

“My interest has always been in preventing and treating chronic conditions,” he said.

A Floridian who attended Duke University as an undergraduate, he helped found a series of free clinics in Eastern North Carolina linking communities with medical students. Just recently, he spent a Saturday precepting medical students at one of the clinics he helped start 25 years ago.

After medical school and residency at University of California-San Francisco, he said he wanted to return to this area and did so as a Robert Wood Johnson Clinical Scholar at UNC in 1996. He has been on the faculty since 1998.

“The health problems of the Southeastern United States are what interest me,” said Pignone.

Early on he collaborated with others to develop a new model for treating chronic conditions and continues to seek ways to refine it as the U.S. health system undergoes transformations with the advent of the electronic medical record, the concept of the patient-centered medical home and the new Affordable Care Act. He has even spent time in Australia collaborating and learning from that public health system about what works to achieve effective colon cancer screening.

Throughout these experiences working with these issues in cancer screening, management of heart failure and others he has developed a special interest in the role of patients’ literacy in the management of diabetes. Thus his involvement with the CDTR, a program funded by the National Institute of Diabetes and Digestive and Kidney Diseases and administered through the NC TraCS Institute, home to UNC’s NIH Clinical and Translational Science Awards (CTSA). The UNC CTSA is one of a nationwide consortium dedicated to accelerating the pace of research translation into better patient outcomes.

“People who are more vulnerable because of low income, lack of health insurance, low literacy and other vulnerabilities tend to have worse outcomes,” he said. “So, we postulated that developing organized programs of care would help them disproportionately, because the more resourceful people with a better start usually could overcome the system barriers, whereas more vulnerable people couldn’t overcome the system barriers.”

Diabetes places a heavy burden on all patients to decipher food labels, count carbs, track glucose levels and medications and juggle an avalanche of information – which is often not altogether clear or consistent – about what is the highest priority. Also, patients with diabetes are at increased risk, and often suffer from, cardiovascular disease. So, some have additional needs to manage more medications and mix in those dietary and exercise recommendations. Pignone points out that a person with low or no literacy must carry all these instructions and data in their heads and it often just proves too much. In addition, he says, sometimes providers inundate patients with information that is not vital to the big picture of managing chronic conditions, making it very difficult for patients to know what to focus on. “We’ve got to figure out a way to disseminate basic self-care training to everyone and then people who are not doing well need to get more,” he said.

The fundamental answer to better management of chronic disease, in Pignone’s mind, and shared by many others, is to improve the reimbursement model.

“We need to transition from the old fee-for-service procedurally driven model to better reimbursing the type of care that we want to encourage,” he said. “The current system encourages you to bring people back multiple times. In the new system, you are going to come in fewer times, but the visit is going to be longer. During the longer visit, you’re going to interact with more people and they won’t be as expensive per minute as your physician.”

“I think we’ve done a pretty good job of implementing that [here at UNC],” he said. The other innovation is doing much more pre-visit work, he said. This involves ordering lab work or collecting other data so that at the visit, the patient and provider have what they need to make good decisions and solve problems then and there.

“We monitor people who are doing well too frequently and we make it too hard for people who are not doing well to get in for appointments,” he said. In his own practice he has made adjustments about follow-up intervals for patients who are doing well, so that more appointment slots open up to take patients who are not doing as well, and to make those visits longer.

It is a tall order to work for systemic change, but Pignone seems unlikely to let up anytime soon. Perhaps having a family with two children, ages 11 and 8, for whom he coaches Little League baseball and with whom he enjoys traveling, gives him that momentum to want to have a better health care system in their future. After all, he already embraces a certain amount of daily challenge – as a devoted Duke basketball fan working on the UNC faculty.