Redesigning Care for High-Cost, High-Risk Patients
The aim of healthcare providers to get better outcomes at lower costs needs to accommodate high-cost, high-risk patients. Half of the US’ healthcare spend is dedicated to the top 5% of the citizens with the highest spend, with the top 1% representing over 20% of the total cost of healthcare. High-cost patients are the most in need of medical care, and are often at the end of their lives, suffering with multiple chronic issues. By developing a better approach to their care, costs can be lowered and patient quality of life can be improved. Under the Hospital Readmissions Reduction Program, readmission rates have dropped, but in 2014 Medicare fee-for-service programs spent $173bn on 9.7m hospitalizations through Medicare. Hospitalizations put patients at further risk, with every subsequent admission raising the risk of mortality. Chronic disease care, if addressed through triage and accessible clinics can decentralize care from hospitals to other facilities, reducing hospitalizations. Outpatient alternatives need to be accessible, as transport forms a serious barrier to treatment for those with chronic diseases. Digital approaches are being explored to create a system of nonemergency medical transportation to ensure that chronic care patients make their regular appointments. Identifying those at risk is key for enacting triage systems and implementing the use of technology in alternative care models. Remote monitoring technology, however, may lead to initial higher rates of hospitalization as issues are identified. Reforming the system to provide more patient-centered care, keeping patients alive at home for longer with hospitalization, is important for addressing the problems for high-cost, high-risk patients.
Amid the political uncertainties that continue to cloud the future of U.S. health care, one thing hasn’t changed: Patients, clinicians, health plans, payers, and policy makers are still striving to achieve better outcomes at lower costs. Given the heavy financial burden that health care is imposing on the country, the top priority should be fundamentally changing the way we care for high-cost, high-risk patients. Redesigning their care is a major way we can improve lives and sustainably reduce overall health care costs.

Almost half of the nation’s health care spending is driven by the top 5% of the population with the highest spending, while the top 1% account for more than 20% of total health care costs. These high-cost patients bear the highest economic risk because they bear the highest clinical risk. They are our sickest and most injured. They are often at the end of their lives, facing frequent hospitalizations for multiple chronic conditions. They are often in intensive care units with ill-defined goals of care. They may undergo tests and procedures that are designed to better characterize and manage complications of chronic conditions rather than prevent or treat them.

To build a better model of care, physicians and leaders of care organizations must begin by asking where we should care for these patients, how we should care for them, and, ultimately, why we care for them.

Where. The good news is that there have been declines in readmission rates under the Hospital Readmissions Reduction Program, which was established under the Affordable Care Act to financially penalize hospitals with higher-than-expected readmission rates for Medicare beneficiaries with select conditions. Nevertheless, hospital spending continues to increase due to the severity of illnesses and prices. In 2014 the Medicare fee-for-service program spent $173 billion on 9.7 million Medicare hospitalizations.

In addition to representing a key driver of health care costs in the United States, these hospitalizations are associated with risk for our patients. Each hospitalization depletes physiologic reserves, leaving patients at a higher risk of early readmission. Each additional readmission is associated with a higher risk of mortality.

Many hospitalizations may be preventable for patients with chronic diseases, particularly with timely access to alternative venues of care that can act quickly to address the signs and symptoms of decompensation. The Ambulatory Cardiac Triage, Intervention, and Education Unit at Brigham and Women’s Hospital and the Duke Heart Failure Same-Day Access Clinic are two examples of how on-demand access to intensified outpatient management can decentralize care from the hospital, thereby improving outcomes and lowering costs through fewer hospitalizations.

The CareMore Health System, of which we are both leaders, has pioneered the role of early intensive chronic-disease management in neighborhood-based care centers and Extensivists, physicians who follow high-risk patients across multiple settings (hospitals, skilled nursing facilities, and post-discharge clinics) to make sure there is appropriate continuity of care across settings.

How. Novel outpatient alternatives are only effective if they are accessible. Transportation barriers are common among patients with chronic diseases and represent a significant impediment to improving patient outcomes. Among patients receiving dialysis, for example, those who rely on a transportation service are at an increased risk of missing hemodialysis treatments. Intensive chronic disease management programs only work when patients can get to their appointments in a timely manner. Seeking to further improve our patients’ ability to access preventive and chronic care services, CareMore has partnered with Lyft and National MedTrans to test digital approaches to nonemergency medical transportation. The pilot program has shown lower wait times, lower costs, and higher patient satisfaction.

Better transportation to better outpatient care models may lead to better outcomes. But we also need better means of identifying at-risk patients. There is significant potential to triage patients with subclinical and preclinical decompensation of chronic diseases through high-value approaches to remote monitoring. But the value of these technologies remains poorly understood.

The relentless pace of technology has produced numerous products and services to monitor patients at home, but few have been tightly integrated with alternative care models. One exception may be CareMore’s Neighborhood Care Centers, where a team not only delivers the care but also remotely monitors data collected by patients in their homes to determine when that care might be needed for conditions such as heart failure, diabetes, and hypertension. The care team, which has gained the trust of its patients through longstanding relationships, can intervene when it spots worrisome trends through remote monitoring by either modifying a patient’s self-care regimen or scheduling an on-demand appointment for in-person evaluation and multidisciplinary management in a Neighborhood Care Center.

Without the widespread use of such care models that manage patients in the community rather than in the hospital, the use of remote monitoring technology may paradoxically produce earlier and higher rates of emergency department use and hospitalization. As a result, the evidence base to date remains mixed as to whether remote monitoring improves the quality of care.

In the traditional fee-for-service reimbursement model, it’s often difficult to demonstrate that these technologies are justifiable on a return-on-investment basis. Remote monitoring in the context of alternative payment models, such as fully capitated medical groups or health systems, can improve the value of care through increasing quality, lowering costs, or both — because the cost savings produced by these technologies are accrued to the organizations that invest in and implement them. The population-based payment models of Medicare Advantage and Medicaid managed care are examples of a reimbursement environment in which proven technologies could be widely adopted. Capitated payments enable organizations like CareMore to invest in the care management capabilities and digital infrastructure needed to validate and implement technologies that can help patients stay out of the hospital.

Why. In uncertain and changing times, we physicians often ask ourselves why we entered medicine in the first place. Ever-growing demands on physicians’ time for administrative, rather than patient-facing, tasks have led physicians to suffer more burnout than other workers in recent years. We often revisit our original motivations when our children and students ask us why we do what we do, but the most frequent and intense reminders occur at the patient’s bedside. We are reminded of the joy of delivering health care. It goes beyond simply meeting measures of health and survival to deliver and redesign care in a way that better meets the goals and needs of our individual patients.

Patients participating in Patient-Centered Outcomes Research Institute studies have identified being alive at home without hospitalization as a top goal. Redesigning our care delivery solutions with this patient-centered goal in mind can create a virtuous cycle in which better patient engagement leads to better outcomes at lower costs.

Changing the care paradigm is an opportunity to better serve the interests of our patients and the public good by thoughtfully challenging the status quo. The suboptimal value of legacy care models, especially for those highest-cost, highest-risk patients, and the potential for patient-centered care outside the hospital present a fertile opportunity if we have the will to develop, evaluate, and implement a new way of care.