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High-Need, High-Cost Patients
There is consensus that healthcare costs are too high, which we have considered from a number of perspectives. Here, I want to look at the small number of patients who use a disproportionate share of the resources—the high-need, high-cost patient. If you can identify such patients prospectively, care management resources could be deployed cost- effectively, as most studies of care management methods in patients selected on the basis of a single diagnosis yield disappointing results. Recently, Berkman and associates published an extensive review of multiple databases and a literature review to examine the state of the art. 1 The authors point out there is no single definition of this group of patients. Previous studies have looked at multiple chronic diagnoses, mental illness, patient demographics, patient beliefs about their health, (and also their beliefs about the efficacy of medical interventions.) Previous utilization has been examined, but has not proved as robust as hoped as a way to predict future utilization. In their study they found an association with the number of chronic conditions, amplified by behavioral health conditions and “social risk factors.” Savitz and colleagues published an editorial critique of the paper. 2 They agree with mixing both quantitative and qualitative data, as was done in the review, and particularly cite the emphasis on patient-specific items such as activities of daily living, medication adherence, behavioral health and social risks. They have found similar results looking at their own health plan (UPMC.) They disagreed with the observation that demographic data had no impact on ED or in-patient use, which they have found to be important predictors. In discussing the difference, it seems to me the issue is how well demographics can be used as a substitute for what used to be called socio-economic factors, or now social determinants of health. They also note they include a look-back at utilization over 12 months, where this study used 6 months. I find it ironic the editorial is called a real-world view, as none of the authors in either paper is a clinician. So, let me provide a few observations based on clinical care of dialysis patients, who start out as high-cost patients, but even then, there are different patterns of “high-costs.” First, the high costs may be associated with an acute medical event such as a heart attack, a car wreck, or pneumonia. These events are predictable from an actuarial perspective, but no case management method is likely to prove useful for individual patients. Furthermore, these events probably won’t occur again anytime soon, so they are not good predictors of future needs and costs. Second, the high costs may be associated with serious mental health issues or, more commonly, behavioral issues and substance use disorders. I was in conversation last month with a colleague concerning a patient with progressive chronic kidney disease, who was also psychotic. I commented that my experience trying to provide dialysis to psychotic patients was dismal unless the psychiatrist was able to find effective medications the patient would take. He agreed. But the odds are this patient will end up in the ED at some 1 Berkman ND, Chang E, Siebert J, Ali R. Characteristics of High-Need, High-Cost Patients: A “Best Fit” Framework Synthesis. Ann Intern Med 2022;175:1728-1741. doi:10.7326/M21-4562. 2 Savitz LA, Rice Williams K, Swayze D. Identifying High-Need, High-Cost Patients: A Real-World Perspective. Ann Intern Med 2022;1751767-1768. doi:10.7326/M22-3161. point and someone will try dialysis. Should psychosis be equated to metastatic cancer in considering dialysis? Behavioral issues are different in that they are hard to identify prospectively, and most are not treatable. Furthermore, many are rational from the patient’s perspective. I am reminded of a conversation I came into on dialysis rounds one day. The RN was frustrated because she had tried to convince a patient to stop behaviors that were hurting his overall health. She was young, with small children, and could not grasp that he was middle-aged, with little social support, so getting another year on dialysis did not have any real appeal to him. Certainly, it did not appeal enough for him to give up current “negative” behavior. This also brings up the issue of whose behavior is the real issue. At a conference some years ago, I was presented the case of a patient who skipped a lot of treatments and went out binge-drinking the day his social security check came in. He would then show up in the ER in respiratory distress and the staff would rush him to dialysis to “save him.” I suggested they needed to know some day he was going to wait 30 minutes too long to show up. If they recognized he had a fatal illness, they would do what they could, but might see it as palliative, not curative, care. It would not make his care “better,” but it would make it less stressful for all concerned. Substance use disorders are also a special case. First, they are common—about 12- 15% of the population. Second, they are hard to treat. I can think of only one patient with an active drug use problem, who got sober and stayed that way. If the patient has not gotten sober by the time they get to end-stage disease, there is not much motivation for the patient to change behaviors. This leaves the third group, where knowledge deficiencies, or lack of resources is causing high utilization. This is the group where case-management, or care-management is able to “bend the cost curve.” Unfortunately, this is likely only about 10% of any given population. That turns out to be a lot of people, and, again, identifying them in advance is difficult. And the intervention that turns the tide may not be medical. I am reminded of a patient who transferred to us already labeled as a fluid abuser. Educational interventions by the staff were proving ineffective. But one day, after the “lecture,” an older woman in the next chair leaned over and said: “I used to be hard-headed, too, but then I woke up in the hospital with a tube in my throat, so now I measure out a quart jar’s worth of water and keep it in the refrigerator. When it’s gone, I quit.” He took her advice and became a model patient, even passing on his story to other patients. Is there a moral here? When dealing with the specificity of individual patients, you can predict high-need, high-cost patients about as well as the formulas, but it often does not lead to an effective intervention. The issue is “two-handed.” On the one hand we have the care processes, on the other hand we have the patient. Of course, in many of these cases, continued medical intervention is not going to result in long periods of calm. It might be reasonable, and certainly cost-effective, to move to palliative care. But for that to happen, we must re-think a lot of our assumptions about what people really want from the health care system. Not everyone thinks consumption of medical care at “maximal strength” is an unmitigated good. Maybe we would be better off if we gave up the idea, too. |
Further Reading
Activating Patients - The Achilles Heel of Healthcare Reform? Studies show 25% of the population is not involved in their healthcare, but reform efforts assume wider application of evidence-based medicine is the key to better value. Perhaps it is the Achilles' Heel? Changing Physician Behavior Patient-Centered Care A consideration of the interactions of patient preferences, evidence-based medicine and peer review. Population Health Preventable Spending A new study suggests only 5% of Medicare spending in 2012 was preventable, much of it in frail, elderly patients. Is this good news or bad? Risk, Reward, and Other Reasons Patients Don't Follow Medical Advice Patients often don't do what their doctors recommend. The problem is important and contributes to "bad" outcomes, yet we have little insight into the problem. |