Thursday, February 3, 2011

Medical “Hot Spots” and the Future of Healthcare

Atul Gawande has produced a stunning sequence of articles published in “The New Yorker” that, taken together, provide a visionary look at what healthcare in this country needs to become. The latest addition is an article titled The Hot Spotters. Here Gawande reports on recent results that indicate that a significant fraction of medical expenses are being consumed in the treatment of a very few patients. The conclusion is not that a few people are receiving the best and most expensive care available, rather, the costs are associated with the fact that these people are receiving terrible medical care.

Consider the results from a study performed in Camden, New Jersey.
“His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients.”
The results from a medical data mining firm that provides guidance for corporate plans produced similar results. From one group of 100,000 healthcare participants they found that
“....the top five per cent of spenders—just five thousand people accounted for almost sixty per cent of the spending...”
And who were these expensive people? Consider this one who led in the number of emergency room visits.
“In this employed population, the No. 1 patient was a twenty-five-year-old woman. In the past ten months, she’d had twenty-nine E.R. visits, fifty-one doctor’s office visits, and a hospital admission.”

“’All these claims here are migraine, migraine, migraine, migraine, headache, headache, headache.’ For a twenty-five-year-old with her profile, he said, medical payments for the previous ten months would be expected to total twenty-eight hundred dollars. Her actual payments came to more than fifty-two thousand dollars—for ‘headaches’.”

“Was she a drug seeker? He pulled up her prescription profile, looking for narcotic prescriptions. Instead, he found prescriptions for insulin (she was apparently diabetic) and imipramine, an anti-migraine treatment. Gunn was struck by how faithfully she filled her prescriptions. She hadn’t missed a single renewal—‘which is actually interesting,’ he said. That’s not what you usually find at the extreme of the cost curve.”

“The story now became clear to him. She suffered from terrible migraines. She took her medicine, but it wasn’t working. When the headaches got bad, she’d go to the emergency room or to urgent care. The doctors would do CT and MRI scans, satisfy themselves that she didn’t have a brain tumor or an aneurysm, give her a narcotic injection to stop the headache temporarily, maybe renew her imipramine prescription, and send her home, only to have her return a couple of weeks later and see whoever the next doctor on duty was. She wasn’t getting what she needed for adequate migraine care—a primary physician taking her in hand, trying different medications in a systematic way, and figuring out how to better keep her headaches at bay.”
Gawande provides several more examples of costly patients whose expenses derived from the fact that they were not receiving the type of care they needed. There were numerous causes. Some patients had complex multiple conditions that required much more intense oversight by medical staff to ensure a good outcome. Some were unable physically, financially, or mentally to seek appropriate care, or to follow through with the care they were provided.

One often hears claims that raising the cost to the patient will cut overall costs by limiting unnecessary trips to the doctor’s office. Gawande provides result which indicate how well that works.
“The firm had already raised the employees’ insurance co-payments considerably, hoping to give employees a reason to think twice about unnecessary medical visits, tests, and procedures—make them have some ‘skin in the game,’ as they say. Indeed, almost every category of costly medical care went down: doctor visits, emergency-room and hospital visits, drug prescriptions. Yet employee health costs continued to rise—climbing almost ten per cent each year. The company was baffled.”

“Gunn’s team took a look at the hot spots. The outliers, it turned out, were predominantly early retirees. Most had multiple chronic conditions—in particular, coronary-artery disease, asthma, and complex mental illness. One had badly worsening heart disease and diabetes, and medical bills over two years in excess of eighty thousand dollars. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the E.R.—until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure.”

“The higher co-payments had backfired, Gunn said. While medical costs for most employees flattened out, those for early retirees jumped seventeen per cent. The sickest patients became much more expensive because they put off care and prevention until it was too late.”
The author then makes a point he has made several times now in other contexts.
“The critical flaw in our health-care that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control). For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane.”
In an earlier article Gawande discussed how easy it is for patients to be injured or killed by mistakes in the care they received, because medicine is organized into a collection of individual components, rather than into an organized system. Individuals make mistakes that an in-place “system” would catch.
“Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have... I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.”
The author provides examples of approaches that have aimed at providing better care for this class of “hot spotters.” A different paradigm is required. People have to be available to check up on patients to make sure that prescribed treatment is being followed. People with addictions, or who are in an unhealthy living environment, might be best served by a trained social worker. One example provided consists of a team of doctors, nurse practitioners, social workers, and what are referred to as health coaches. These approaches, which would seem to be more expensive, have demonstrated that they can reduce costs significantly, mainly by eliminating needless emergency room visits and hospitalizations. These approaches all involve more frequent and more involved interactions with the patients. They must include an understanding of the life conditions of the patient and how they might affect health and treatment.

I found this description reminiscent of another article by Gawande that discussed end-of-life care. This highly interactive and personal approach is similar to that encountered in hospice care. The author provided some fascinating study results.

Gawande refers to a study performed by Aetna. Normally hospice care is only provided to patients after they forego all other treatments. Aetna decided they would let a group of patients have hospice care and their normal treatments concurrently. The results would be compared with a control group only following their regular treatment. Both groups had a life expectancy of less than a year. The results were stunning. Patients benefited greatly from having the hospice service available. Within this group, emergency room visits declined by 50% and the use of hospitals and ICUs dropped by two-thirds. Overall costs dropped by almost a quarter. The ultimate conclusion was that the more personal care they received from the hospice workers improved the patient’s health and well being.
“...they had simply given patients someone experienced and knowledgeable to talk to about their daily needs. And somehow that was enough—just talking.”
Hospice care is concerned with trying to maintain quality of life at the current moment. That means worrying about pain and discomfort and trying to keep the patient alert and active as long as possible. Its goal is to bring the patient peace while nature takes its course.

Gawande describes another study.
“Like many people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But studies suggest otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure. They found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer. Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.”
End-of-life patients are by definition “hot spotters” with expensive treatments and frequent hospitalizations. This personalized, interactive, team approach seems to work better and lower costs.

What conclusions can be drawn from all of this?

First, one can state that by changing the manner in which we deliver healthcare to certain classes of patients we can reduce costs without attacking anyone’s fee schedule or drug prices.

Second, the traditional delivery model, where an individual doctors support a staffs of nurses, receptionists, accountants and insurance specialists by funneling through as any patients as possible in a given day, is obsolete. Doctors need to be embedded in teams of physicians with multiple specialties. This team practice has to be large enough to provide the systemic checks and balances that ensure that best practices are being followed and that mistakes are not being made in meditation or treatment. New information technology and electronic medical records should alleviate many of these difficulties.

Third, we need to take advantage of the incentives provided in the recent healthcare bill to demonstrate that some of the techniques Gawande refers to can be applied on a large scale. The type of individualized care will essentially replace some doctor visits and emergency room visits and hospitalizations with the effort of additional, but lower paid staff. If the model demonstrates a cost savings, some of the savings can be kept by the group. That is the incentive.

If the models Gawande describes provide a new model for healthcare, we have the basis for improved health outcomes, lower costs, and more jobs. The cost savings will ultimately have to come from not having to support so many hospitals; there will be fewer medications needed; and probably doctors’ fees would be diminished.

We can live with all of the above.

1 comment:

  1. What a good article. I work in the medical safety training field, and I come across stories, articles, and DVDs of doctors who didn't take the time to really understand what was going on with a patient. They relied too much on tests like MRI, and din't follow through. These cases are becoming more common, and better quality measures should be taken. Complacency leads to injury.


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