Essay: The high price of failing America's costliest patients




Even patients with whom I have the best rapport would probably rather not see me so often.

Sometimes I readmit a patient I cared for just weeks before in the hospital. “Nice to see you again,” I offer with a smile. The usual response, loosely paraphrased: I’d rather be anywhere else.

This reflects not some deep deficiency in my bedside manner (I think), but rather an essential truth about medicine: People want health, not health care. And those who require the most health care and get the least health — high-need, high-cost patients with multiple or severe medical conditions — feel this most acutely.

Leaving aside the moral compulsion to improve the quality and efficiency of their care, there is an overwhelming financial imperative to do so. It’s well known that the country’s staggering health care costs are not evenly distributed. Just 1 percent of patients account for 20 percent of costs, and 5 percent of the population accounts for nearly half the nation’s health care spending.

But exactly who these patients are — and how we can better meet their needs — is less clear.

Misaligned financial incentives

One emerging definition, based on research, focuses on people with three or more chronic conditions who have a functional limitation, such as difficulty dressing, bathing, feeding themselves, walking, taking medications or using transportation.

Functional impairment seems to be a critical distinction between being chronically ill and being chronically ill with “high needs.” Patients with multiple chronic illnesses but without functional limitations have only modestly increased medical costs, and they have incomes similar to the general population.

But those with chronic illnesses and a functional limitation have four times higher medical costs — more than $21,000 annually — and spend twice as much out of pocket, despite having much lower incomes. They visit the doctor more often, use more home health services and are three times as likely to be hospitalized.

There are 12 million such Americans. They are veterans with disabilities, grandparents with Alzheimer’s, young women with lupus, kidney transplant recipients, factory workers with cancers that rage through rounds of chemo.

Three-fourths are white, two-thirds are women, half are older than 65, and more than a quarter did not finish high school. They have more social stressors, such as housing insecurity and social isolation, and many have serious mental illness and substance use issues that contribute to higher rates of emergency department visits, hospitalizations and difficulty navigating the health system. More than 80 percent are publicly insured through Medicare or Medicaid.

“We can’t make the system work unless we do better with this population,” said David Blumenthal, a health policy expert and president of the Commonwealth Fund. “It’s important from a humane standpoint — these are our friends, our family. But it’s also important from a cost standpoint, and the effect on taxpayers.”

Mr. Blumenthal said misaligned financial incentives pose a critical barrier. In fee-for-service medicine, doctors and hospitals are paid for each service, and have little reason to invest in programs that reduce the number of medical interventions or that keep people healthy. The more frequently a patient is seen, admitted, scanned, biopsied or prescribed medication, the better. This is especially problematic for high-need patients, who require an abundance of services, and whose social and medical complexity makes it hard to streamline and coordinate care.

“In our current system, being inefficient means higher revenue,” Mr. Blumenthal said. “It’s hard to do the right thing in fee-for-service. But value-based payment reverses the incentives so they’re aligned with patient and societal goals. When you get the incentives right — when you reward high value instead of high volume — you see a burst of creativity among providers finding ways to do better.”

A California company with a plan

One such burst has come at CareMore Health, a California-based health system and Medicare Advantage plan that specializes in caring for chronically ill patients.

Like other such Medicare Advantage plans, CareMore receives an overall payment from the government for the expected costs of its beneficiaries, instead of separate payments for each service. If it provides care more efficiently compared with predetermined benchmarks, it keeps the difference. (To prevent skimping on care, these plans are required to meet quality standards, cover all traditional Medicare services, and invest savings in additional benefits for members, or lower premiums to attract new enrollees.) Unlike most Medicare Advantage plans, though, CareMore also directly provides the medical care it pays for.

Every CareMore enrollee has an initial visit where a team of doctors, nurse practitioners, dietitians, social workers and behavioral health specialists performs an evaluation of their medical and social needs. The team then tailors its resources — chronic disease programs, nutritional counseling, social support referrals, behavioral therapy — to those needs with the express goal of keeping patients out of the hospital.

In one example, heart failure patients — for whom weight gain can mean fluid retention and hospital admission — get a wireless scale to weigh themselves at home, which sends data to a CareMore team. If team members see a worrisome trend, they can remotely adjust the patient’s medications, or if necessary, schedule a same-day visit.

“In hospitals, we’re great at customizing care,” said Sachin H. Jain, president of CareMore. “We have different intensities for patients with different needs: an observation unit, a general medical ward, an intensive care unit. But on the outpatient side, we haven’t done that. In your average clinic, all patients get scheduled for 15 or 30 minutes, regardless of whether their problem list is empty or 10 pages long. Our model tries to fix that.”

CareMore says it spends about twice as much as traditional Medicare on prevention and disease management programs for its sickest patients — but only half as much overall. In 2015, CareMore patients had 20 percent fewer hospitalizations and spent 23 percent fewer days in the hospital compared with fee-for-service Medicare patients of similar health status.

Other systems have shifted their focus in similar ways. Geisinger Health Plan in Pennsylvania, for instance, pays for extra nurses in primary care offices to help patients manage their chronic diseases: filling prescriptions, checking blood pressure, ensuring regular checkups. It employs case managers devoted to overseeing tenuous, often costly, transitions between the hospital and home for complex patients. A single prevented heart attack, amputation or stroke can more than offset the extra cost of another set of eyes.

Another program, known as the Program of All-Inclusive Care for the Elderly (and in Pennsylvania, known as LIFE programs) gets fixed payments from Medicare and Medicaid to keep patients out of nursing homes and living in their communities.

Although the program serves people who are generally frailer than other Medicare patients, it has led to lower costs, fewer hospital stays, higher patient satisfaction, and possibly, longer lives. Over the past decade, it has grown to more than 100 sites in 32 states from about 40 sites in 22 states. And it recently received a flood of funding from private equity and venture capital firms betting these providers can cut costs by keeping patients in homes and out of institutions.

Better care for high-need patients will probably require accelerating these types of innovations, with an emphasis on paying for more effective services instead of intensive services. Another important step would be aligning payment models across the health system — Medicare, Medicaid, private insurers — so providers don’t have to design different care models for differently insured patients.

More fundamentally, progress may hinge on expanding our cultural conception of medical triumph beyond robotic surgeries and genome sequencing to include keeping a 74-year-old woman with heart failure, emphysema and breast cancer — with eight medications, four subspecialists and zero next of kin — out of the hospital for the next year.

What’s often lost in talk of dollars and drugs is a core that those of us providing and receiving care feel every day: No one wants to be in a hospital. Patients want independence. They want dignity. They want to do what they love and be with whom they love. If the goal of medicine is to promote health — not health care — maybe we’ve been doing it wrong. And we’re all paying the price.

Dhruv Khullar is a physician at NewYork-Presbyterian Hospital and a researcher at the Weill Cornell Department of Healthcare Policy and Research.





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