The uphill climb of complex care management

In an ironic analogy to the recent Occupy Wall Street movement publicizing the wealth gap between America’s elite and the general public, the health care world also has its own infamous 1%. According to the Agency for Healthcare Research and Quality’s 2012 report, the top 1% of health care seekers incurs nearly a third of the nation’s $1.26 trillion yearly health care expenses (and up to half of this expenditure can be traced to the top 5% of medical consumers).

If you have watched the news in the last year, it should be no secret that the health care cost crisis has reached critical mass in the United States. Many of the physicians and legislators tasked with solving this problem have targeted this 1% as a major barrier to the reduction of national health care costs.

An illustrative case

I met Ms. S on a Monday during my inpatient rotation on my medicine clerkship. She is a 63-year-old woman with a worn, cachectic face covered by leathery skin and shockingly severe tardive dyskinesia. She was admitted for management of cellulitis following a finger laceration sustained while cooking. Her primary care physician prescribed a five-day course of antibiotics, with which she was compliant for two days before cessation due to improvement of her pain.

Two days later, she informed her pain management physician of this incident during a routine visit. She was admitted for cellulitis a week later and her condition ultimately required amputation of the distal phalanx of the first digit on her right hand. Ms. S has a laundry list of medical problems, the most notable of which being obesity, psychotic depression, prothrombin gene mutation with history of multiple thrombotic events, and chronic pain from cervical spondylosis and a motor vehicle accident. Considering only the four-month period prior to my encounter with her, Ms. S had been seen by 12 unique providers during hospital admissions or office visits to specialties including hematology, bariatrics, pain management, neurology, and infectious disease. One can only imagine the exponential degree to which this number would increase if the entirety of her health care consumption were to be queried.

Ms. S’s story illustrates the paradigm of the 1% in health care and the need for meta-coordination of the most complex patients. This topic was discussed quite eloquently in two pieces in the New England Journal of Medicine. First, Dr. Hong and colleagues argue for the necessity to transition from the fee-for-service model to a global-payment or shared-savings approach in order to facilitate complex care management (CCM). In the second, Dr. Press uses sports analogy to explore a team approach to care management and the need for strong relationships amongst a patient’s multiple providers.

In the case of Ms. S, termination of her antibiotics prematurely led to her own personal morbidity as well as unnecessary health care expenditures. In a CCM model, the patient’s primary care physician would have felt an obligation to follow-up with the patient to confirm her medication compliance, because his/her earnings would depend on patient and cost outcomes, as opposed to units of services provided. In this way, the hospitalization may have been avoided — saving Medicare thousands of dollars and the patient a finger.

However, the primary care physician should not bare all of the blame. The patient met with her pain management physician in the interim who was made aware of the finger laceration and antibiotic course. Implicit in the success of a CCM model is the comfort of providers with professional relationships and interactions. In his article, Dr. Press posits that electronic medical records and the use of hospitalists may impair the development of inter-physician social relationships that have the potential to benefit the patient. Had the pain management doctor reached out to the primary physician to discuss updates on Ms. S, perhaps her cellulitis and subsequent amputation could have been avoided. The fee-for-service mindset disincentivized a simple call between physicians, as neither was vested in the ultimate outcome of the patient beyond their moral and ethical inclinations.

Of course, the case of Ms. S is merely anecdotal and sweeping changes in the landscape of health care delivery must be based on big data. Analysis of this data is beyond the scope of this discussion — in short, no clear morbidity, mortality, or financial benefit has been demonstrated with CCM thus far.

As a medical student, I struggle to comprehend the enormity of variables rolled into health care delivery and consumption. The organizational decisions being made daily by the administration of physician practices, hospitals, HMOs, and state and federal government sum to the $1.26 trillion yearly health care expenditure mentioned above. Those of us on the cusp of a career in medicine are charged with stretching these dollars farther and improving the efficiency and quality of care provision. This means recognizing failures like those that occurred in the case of Ms. S, and thinking outside the box for potential solutions.

CCM seems an obvious starting point, as a central coordinator of a complex patient’s multiple medical problems makes logical sense. However, we must never stray from the data. If, after sufficient scrutiny, CCM shows no benefit for patient outcomes and fiscal responsibility, we must be quick to jettison this idea for a more savvy solution. Regardless, it will be an uphill climb. The Unites States currently sits 37th on the World Health Organization’s ranking of world health systems, while consistently reporting the highest spending amongst these countries. Delivering better care, at a reduced cost, to the most burdensome 1% of US health care consumers may be the first step toward reversing this disparity.

Joshua Horton is a medical student.

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  • lurking for answers

    The CCM model would be good if you can find the primary care physicians who are willing to actually CARE for these patients. I’m not a 1%-er in cost, but definitely in rarity of conditions. I have attempted to find a primary care physician to quarterback for me and round up all my specialists, but so far (until a week ago) I’ve been turned down flat. Once I fill out the intake forms and the doc sees the list of conditions, a nurse comes in and tells me that while the doctor IS taking new patients, the practice will NOT be taking me.
    I’m far from alone in this. There are hundreds of thousands of patients that are in the same position. For one complicated disease, there is a specialist; add another on top and you’ve got a mess. I see specialists in three different states because I have to, not because I like the travel.

    I would like to see dedicated primary care physicians or even a primary specialist trained for complex conditions to coordinate care.

  • Thomas D Guastavino

    I have a question. Anyone is invited to answer. Do any of the global payment health care models take into account patient motivation or secondary gain issues? It seems that those who are pushing these panaceas for all the ills in our health care system have assumed that all patients principal motivation is to get better.

    • lurking for answers

      This is a very valid question. It calls in another, highly active post here on KMD:
      Again, I don’t have an answer. But from my perspective, there is a population of willing takers for any “assistance” in order to avoid taking responsibility for either their health or financial wellbeing.
      (I’m going to hide for a while and let that blow over)

      I can actually answer you in my case though: I see my docs because they know their medicine. I pay them whether they are in or out of network, or no network at all. I am doing and have done everything in my power to mitigate, ease or cure my conditions. I would love to never have to see any of my docs again and plunge back into a full, physically painless life. Once my kids are out of high school, I will likely sign my own DNR. I accept that everyone has to die of something, so if it is one of my illnesses, I have no intention of going through “heroic measures” to prolong my “existence.”

      I just don’t want something stupid, like a sinus infection or strep throat, to take me out because I can’t find a doc willing to treat me!

      • Thomas D Guastavino

        You are clearly intelligent and your principal reason for seeking medical advice is to get better. You are also willing to follow advice, take responsibility for your own actions, and actually pay for the services you receive. You would be a pleasure to work with as a patient.
        If every patient were like you then global fee schedules might work. Unfortunately, not all patients are like you. I simply cannot see how having the providers accept financial responsibility for their decisions is going to work when you are dealing with an unmotivated or secondary gain patient population.

        • lurking for answers

          Thank you for your comment, I try very hard to stay as healthy as I can.
          I would however, like to revisit an ongoing question that I have continued to ask since your “Blackjack” post:
          How do patients with chronic or complicated medical issues find doctors willing to treat them?

          If I am cut from the deck, at “face value,” because of a list of diagnoses, how will the doctor ever know that I am “willing to follow advice, take responsibility for my own actions and actually pay for the services I receive?”

          You know that there will always be a certain number of patients that ARE looking for secondary gain, but there are also genuine, responsible people with chronic/complicated illnesses who do need care. If you take us at “face value” we both lose.

          • Thomas D Guastavino

            I still see a lot of these patients, initially giving them the benefit of the doubt. However, I quickly extricating myself if deemed necessary.

    • guest

      The beauty of the model is that the patient’s level of motivation doesn’t really matter.

      If the patient is unmotivated, it’s the clinician’s fault for having failed to properly “engage,” “educate,” and “motivate” the patient.

      • Thomas D Guastavino

        Time to increase my “Your Fault” Insurance.

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