The Healthcare Imperative Lowering Costs and Improving Outcomes: Workshop Series Summary (2010) / Chapter Skim
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16 Medically Complex Patients
16 Medically Complex Patients
Pages 493-516
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Arnold Milstein of the Pacific Business Group on Health opens this session by reviewing promising initiatives to lower per capita healthcare spending and improve clinical outcomes for medically complex patients. He reports that two areas of reform have yielded the largest impacts: (1)
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Department of Health and Human Services identifies several policy areas that could further support tertiary prevention in individuals with multiple concurrent chronic conditions. Since medically complex patients have often been excluded from participation in randomized controlled clinical trials, he suggests that the external validity and generalizability of these studies to this population are limited.
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PAYMENT POLICIES AND MEDICALLY COMPLEX PATIENTS Arnold Milstein, M.D., M.P.H. Pacific Business Group on Health and Mercer Health & Benefits Public and private sector policy makers seek provider payment reforms that will both improve clinical outcomes and reduce healthcare spending substantially.
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The Implied Public Policy Prescription Success in improving the care of medically complex patients and lowering total per capita healthcare spending is likely to require addressing these three pivotal cofactors. The following prescription illustrates how federal policy could accomplish this.
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that public and private payers share pro rata in the expense of efficiently providing technical assistance to support both the successful adop tion by providers of multidisciplinary primary care teams for the severely ill and the standardization of inpatient care processes using models developed by benchmark providers; and (2) that a substan tial portion of federal comparative effectiveness research funds be dedicated to comparison of options for accelerating providers' rate of adoption of innovations demonstrated to deliver better clinical outcomes and lower per capita spending for medically complex patients.
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. Palliative care provides a solution to the difficult challenges posed by medically complex patients.
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Table 16-1 details ease of policy implementation and potential barriers. Workforce A second major barrier facing the expansion of palliative care services is the lack of palliative medicine physicians.
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training slots Requires Congressional action to approve but could integrate into efforts currently under way with respect to primary care. Loan forgiveness Moderate Competition from other specialties.
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Include Moderate Guidelines for palliative care service palliative care components at smaller hospitals in accreditation and long-term care facilities need to requirements be developed; resistance from Joint Commission given sizable number of hospitals and nursing homes that currently lack programs. Evidence base Develop Office Complex Requires Congressional act akin to of Palliative Care Office of AIDS Research.
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Several policy initiatives are likely to have a major impact on improving care for persons with serious illness. First, the GME cap should be lifted to allow the expansion of palliative care fellowship training programs, and currently unused GME slots should be redistributed to support ACGMEapproved palliative medicine fellowship training.
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For example, providing hospitals and nursing homes with bonus payments linked to palliative care delivery with a transition over 5 years to penalties for institutions not providing palliative care, requiring palliative care services as a condition of bundled payments, and adjustment of current physician reimbursement pay scales to support time-intensive goals of care discussions and care coordination would lead to a rapid growth in palliative care services and lower costs. Similarly, a new Resource Utilization Group category for palliative care reimbursement to nursing homes through Medicare would help counter the misperception that palliative care is incompatible with the restorative focus of nursing homes and increase access to palliative care for nursing home residents.
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This paper has outlined policy initiatives in four key areas that would rapidly bring palliative care to scale in the United States and help address the quality and costs issues outlined in this report. PAYMENT AND BETTER CARE OF COMPLEX PATIENTS Ronald A
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Care Gaps -- An Alternative Approach Care gaps are defined as evidence- or consensus-based patient clinical needs as informed by age, gender, comorbidities, physiological parameters, and other factors. In general, each care gap is known to be directly associated with improved intermediate or clinical outcomes.
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This commonsense model addresses gaps in the typical fragmented care model experienced by many Americans today. Geisinger Care Gap Management Example Geisinger has launched a series of initiatives focused on closing care gaps; here we specifically describe the management of patients with diabetes.
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. First, care gaps are identified for each individual patient within CDIS by comparing her electronic information against evidence-based care needs as defined in the bundle.
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Of course, this approach also requires fundamentally reengineered care processes. At Geisinger we seek to reengineer care processes by hard-wiring evidence-based care, eliminating waste, automating care processes as feasible and appropriate, delegating care to the least-cost competent caregiver, and seeking to engage and activate the consumer-patient and her family as team members in the care journey -- all supported by our EHR, analytic databases, and intelligent decision support.
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With the aim of reducing uncoordinated care expected to lead to excessive healthcare costs, "medically complex patients" are those exhibiting patterns of use of care demonstrating lack of coordination (Owens, 2009)
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This paper focuses on the population with multiple chronic conditions as a group at high risk for uncoordinated care. In addition, the MCC population serves the purpose of introducing several policy areas that could be explored to support care coordination and chronic care management.
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. To prepare for an increasingly medically complex population, all health professional students likely to care for patients with MCCs need to learn how to prioritize treatment of chronic conditions in individuals, deal with drug-disease interactions, and consider patient preferences when making care plans.
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In addition, patient incentives to adopt healthy lifestyle choices, such as reduced cost sharing, should be studied to see if they reduce the burden of disease and lower healthcare costs. Looking Forward By addressing these policy areas, providers and patients will have better information and incentives to coordinate and manage the care of complex patients, such as those with multiple chronic conditions.
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2007. Mortality rate in veterans with multiple chronic conditions.
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2007. Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs.
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2002. Prevalence, expenditures, and compli cations of multiple chronic conditions in the elderly.
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