Ellen Pautler has weathered surgery to fuse most of the vertebrae in her neck. Rheumatoid arthritis sometimes flares in her joints. Her right shoulder doesn't work as well as it used to.
Pautler has toyed for five years with the idea of reverse shoulder replacement surgery. Doctors have told her she'll only get one stab at the procedure because they can't go back and do it again.
It helps explain why she recently used an online "shared decision-making tool" to more thoughtfully consider her options – even though she's been a registered nurse for 42 years.
"You want to be educated about what questions to ask," she said. "I kind of knew but when it's you, the anxiety builds up and you ask yourself after a doctor visit, 'Did I do the right thing?' 'Did I ask the right questions?' The program was a reassurance that I was looking into this the way I should be."
Pautler, 63, of Lancaster, used a free software program called Welvie, offered by her health insurer, BlueCross BlueShield of Western New York. The program is one of several designed to help patients considering surgery better assess the need, risks and potential benefits.
Such programs generally also help users come up with questions for their doctors and surgeons, better prepare for surgery, and prime patients for the best possible recovery.
"When a patient is seeking a consultation with a physician, it's a lot of information over a short period of time. It's very hard to digest and absorb that," said Dr. Thomas J. Foels, chief medical officer for Independent Health, a Williamsville-based insurer that uses a similar program called Healthwise.
"In a physician's conversation with a patient, try as they might to cover all of the points, sometimes things are discussed and forgotten," Foels said. "Sometimes things are omitted. It puts a lot of pressure on a patient to commit one way or the other. The bottom line is that the informed patient is much more likely to make the right decision for them and their family."
Health insurance companies have turned to shared decision-making tools in a medical climate where the number of elective surgeries has climbed along with the number of aging Baby Boomers.
Knee and hip reconstructive surgeries in the U.S. surpassed 1 million last year; a tally expected to more than triple by 2030, according to the National Institutes of Health.
That surge will come at a time when a growing number of Americans have high-deductible health insurance plans, including one in four members of BlueCross BlueShield of Western New York.
"That is forcing people to think more critically about the medical services that they're using," said Jennifer Johengen-Vogel, senior director of health management with the Buffalo-based company.
Welvie starts with an online survey. If you're sure you want surgery, it takes you down one track; if you're thinking about surgery but would consider other options, the track changes. The online tool helps users:
1. Get the right diagnosis
Users develop questions and personal medical information to take to a doctor visit, making more efficient use of limited time.
2. Choose the right doctor
This step prepares people to interview and select the right surgeon. Members can put together questions specific to their needs and circumstances – and also are encouraged to run them by their primary care provider. Users also can watch mock interviews to gain more confidence for this important step.
3. Make a decision
Doctors, including surgeons, typically provide non-surgical options that can often be tried before surgery is considered. They might include physical therapy or exercise, chiropractic or acupuncture, and possibly medication. Welvie and other shared decision-making tools help users weigh the risks and potential benefits of each. Some users might want to consider how particular passions – say skiing, running or playing tennis – could impact what steps to take before considering surgery, or the timing of a procedure.
4. Surgery locations
Potential inpatient and outpatient options can be weighed. Members also can learn more about what anesthesia will be used and why that's important.
5. Prepare for surgery
Users can compile calendars and medical history charts for health provider appointments and procedures. Information about potential challenges and the use of pain medications is available. There is a cost checklist. "We're encouraging people to take these pieces and have these conversations with their docs," Johengen-Vogel said. There's also a list of things to bring to surgery.
6. Recover at home
Welvie can help users set up their living quarters in advance to safely return post-surgery, particularly if mobility is limited. Users and their doctors can create a timeline that shows how physical activity should return. Wound care, nutritional information and furniture rearranging are covered. "These are very simple things but people don't always think of them," BlueCross BlueShield spokeswoman Amber Ciesiulka said.
"After you've created these profiles, you have the ability as a member to go back in, fill in checklists and print them off" to bring to a health provider, surgical center or hospital, Ciesiulka said.
BlueCross BlueShield’s eligible commercial and Medicare Advantage members can visit welvie.com to get started. For questions or help enrolling in the free program, members can call 877-386-6556 from 9 a.m. to 7 p.m. weekdays or e-mail email@example.com.
Eligible members get a $25 amazon.com gift card after finishing the first three steps of the program.
Pautler and her husband, Ken – a retired salesman who went through the first three steps, even though he isn't considering surgery – each got a gift card.
"We're in the process of revamping the kitchen and I bought some curtains," she said. "I spent the money for him."
Because a growing number of elective surgeries are taking place in outpatient surgery centers, Independent Health is among insurers now bundling payments for surgeons who effectively help manage surgical prep, the procedure and followup, Foels said.
"When you get home, you start to do stuff," he said. "You have to." Infection rates tend to be lower outside a hospital setting, he said, and the comfort level and food to be higher.
In making such tools available, insurers also are mindful that unnecessary procedures driving up health costs for all.
“Unnecessary care and waste have been well documented in the medical literature,” said Dr. Richard Vienne, Univera Healthcare vice president and chief medical officer. “A 2012 report from the Institute of Medicine calculated that about 30 percent of health spending was wasted on unnecessary services, excessive administrative costs, fraud and other problems."
Williamsville-based Univera includes Choosing Wisely, another shared decision-making tool, in its online wellness repertoire.
Back surgery follows hip and knee replacements as the most common elective surgeries in the BlueCross BlueShield fold, but Johengen-Vogel said the Welvie tool can be used when considering others, including cardiac and stent procedures.
Shoulder surgeries, too.
Pautler – a wellness nurse on the independent living side of Fox Run continuing care retirement community in Orchard Park – said Welvie helped her better prepare to talk about a potential surgery first with her rheumatologist and then with an orthopedic surgeon. A series of discussions led each of them to conclude it was better to put off a procedure for a few more years, if possible.
The process also helped her discover a surgeon accomplished in performing reverse shoulder replacement surgery, in which the deltoid muscle is used to replace a torn rotator cuff to power and position the arm. The procedure is still somewhat novel in the region.
"My range of motion isn't what it could be but I still have real good range in my right arm," Pautler said. "I'm just careful. I know my tolerance, that I can't do heavy lifting with that arm…
"A simple appendectomy is one thing but when you're starting to get more involved with the latest and the greatest, you want to know where your surgeon stands. Welvie helped me fine-tune everything. It gave me more confidence. When you're dealing with your own medical issues, sometimes you get overwhelmed, you get anxious. You're not always thinking clearly about what's being said to you. Taking the survey in your own home, writing stuff down or printing stuff out, and thinking about it, makes you more relaxed. And this gives you more avenues to get help if you need to talk to someone."
The top three insurers in the region each use a slightly different tool to help members decide whether to have elective surgery and, if they do, how to help manage it in the safest, most effective way possible:
BlueCross BlueShield of WNY
Welvie helps would-be surgical patients zero in on the right diagnosis, choose the right doctor and make the right treatment decisions. If surgery looks to be the best option, the website also helps users pick a surgery location, prepare for surgery and recover at home. Learn more at welvie.com/public/tutorial.
The insurer uses Healthwise – a nonprofit health education organization free from conflict with the medical device and pharmaceutical industries – to help patients who are considering hip or knee replacement surgery. Members can access help here.
Univera also was among the first insurers to embrace Choosing Wisely, a nationwide initiative to promote shared decision making between patients and doctors to improve the quality of care, and reduce unnecessary spending on services that have little or no proven benefit. Choosingwisely.org can help doctors start open, honest conversations about options for care, tests and procedures so that the chosen treatment is evidence-based, doesn’t duplicate other tests or procedures, and is safe and necessary. The website is accessible to anyone.