PHS 795 student Scott Reetz writes:
Dr. David Blumenthal of the Commonwealth Fund has authored a prospective paper in the most recent issue of the New England Journal of Medicine which I found to be a current example representing the public health frameworks discussed in class. In the article, Dr. Blumenthal raises the concern that in our current health care environment, 5% of patients account for 50% of healthcare expenditures in our country – a figure that is likely to worsen according to his estimations. These High Need High Cost patients, as he labels them, represent a diverse population of patients and as such requires an equally diverse understanding of these patients’ varying health care needs and the factors contributing to their ailments. I found this article particularly optimistic because Dr. Blumenthal felt confident that the transition from a fee-for-service reimbursement model to a value-based payment system in American healthcare may incentivize providers to take a more collaborative multi-disciplinary approach to target the social support and environmental factors that have led to adverse health outcomes for these patients. There is an accompanying interview with Dr. Blumenthal that I found to be equally thought-provoking, as well.
http://www.nejm.org.ezproxy.library.wisc.edu/doi/full/10.1056/NEJMp1608511
The Fantasy Equation 
Scott, I really like that you found this and brought it to our attention. The second I read “5% of patients account for 50% of our cost expenditure” I thought: get them some primary prevention and better access!!! Not only would a value-based payment system do more to help health care providers to work together in a more creative fashion, but it might lead ‘the system’ as a whole to think about WHY these patients are coming in in the first place. The diverse nature of the population should lead providers to develop a diverse set of interventions, both on the prevention and the treatment sides. I liked his interview too!
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I think the three of us are on the same page: 5% of patient’s accounting for 50% of healthcare costs is jaw-dropping. Alex mentioned a prevention-based direction of care that could significantly reduce such costs. While I agree that the preventative approach could make a significant impact, there’s a problem with building appropriate channels for identifying these sour states of health earlier: how? One of the many limiting factors to the preventative approach would be building one in the first place – how well understood are the diseases that burden this 5% of patients? Are they identifiable at early stages and if so, can they be appropriately treated? These are also likely to be reasons why the diseases that strike the high need, high cost patients: the health conditions aren’t well understood. Therefore, might we also harvest benefits from researching said diseases with the intention of improving current treatment plans?
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This article was insightful and brought to mind the in-class lecture by Dr. Jonathan Jaffery. The staggeringly high percentage of utilization of health care among a small population seems outrageous at first glance. However, it becomes more understandable when thinking about the complexities of these individuals and what complex care entails. Understanding the needs of the populations is vital to delivery reform and to changes payment. The unwarranted variation and lack of standardization and evidence-based guidelines prevents achievement of ideal outcomes. Moreover, this variation is extremely costly. Emphasizing strategies to redesign workflows and bundle care may help to emphasize team-based care and engage patients in the improvement of processes. Ultimately, the alignment of these incentives can reduce the unwanted variation and result in significant cost-savings.
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I found Scott’s article interesting to read. The statistic that 5% of patients account for 50% of healthcare costs shocked me as much as it shocked Alex, Daniel, and Joe. I believe that these High Need High Cost (HNHC) patients deserve efficient comprehensive treatments for humanitarian reasons.
Prevention would be the preferred way of solving this problem, but I don’t think that prevention would have worked for all these patients. Some patients ended up as HNHC due to a lack of social support, lack of education, or lack of access to care. I believe that these patients could be helped by policies geared towards prevention. However, other patients have suffered debilitating injuries that limit them functionally, or have congenital conditions that cause them to stay bedridden or in a chronic state of illness. I believe that hope for these unpreventable cases lies in the creation of comprehensive, multi-disciplinary care teams.
I think that the creation of efficient care teams is dependent on the development of electronic health records, incentivizing policies such as those created for Accountable Care Organizations, and the greater integration of social health workers, physicians, nurses, and other caretakers in care teams.
-Omar
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Understanding the high need high cost population (super-utilizers) and how to reduce associated costs has been an issue that his been getting increasingly more attention recently. In thinking about the super-utilizer population, Dr. Remington’s words are something I continuously come back to. Dr. Remington reminded us that changes in the population don’t ‘just happen,’ rather, the changes we see are designed by our system, both the negative and positive. The super-utilizer population is an example of a problem that might have been created, or at least exacerbated, by our system. From speaking with some experts in the public services field, one way that the super-utilizer problem was ‘designed’ by our system is with how separated different social service providers are. For example, an individual who might be identified as a super-utilizer could have multiple case workers coordinating various needs. With various services being handled separately, there is a lack of cohesive knowledge of the services a super-utilizer is using, and some needs fall through the cracks. When an individual’s needs aren’t fully and efficiently met, this means that they are likely to keep seeking out services and driving up costs. Approaching this issue with a reverse engineering mindset, trying to see where the system is creating or exacerbating the problem, would likely be helpful to understanding the systemic issues at play. However, we will likely discover that the root causes are extremely difficult to resolve and that we need to both address the symptoms of the problem and the root causes.
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