Managing Complex Patients

As the post yesterday suggested, finding and managing high-cost patients is a health system pre-occupation.  Employers, who still provide health coverage for the majority of Americans, have engaged in a number of initiatives toward this end.  A Commonwealth Fund brief describes one such effort, the Intensive Outpatient Care Program.   (Comm. Fund Report)   This program was initially developed by the Pacific Business Group on Health and Boeing, and subsequently, with the aid of various grants has expanded to a number of employers in the western US.  The key feature of this program is the common strategy of embedding dedicated care coordinators in primary care practices and medical groups.  Critical success elements, or “guardrails” in the program include:  a care coordinator who maintains a close relationship with the patient; within a month of enrollment, the care coordinator makes a home visit and assessment; the care coordinator and patient communicate at least once a month; the patient and care coordinator create a shared action plan, including patient-set goals; in-person introductions are made by the care coordinator to various support services; and patients have access to non-emergency care 24 by 7.  Integration with behavioral health care was also highlighted.

This isn’t cheap, it requires hiring, training, IT support, call center support, etc.  That is funded in this program by additional per patient monthly fees or in some cases an additional upfront payment for infrastructure.  Nothing in the report talks about net impact on health spending, but typically the expense involved in running this kind of care management program is greater than the net cost savings.  Quality, and participant health, are almost certainly improved in these programs.  One barrier to getting a better ROI remains identification of appropriate patients.  As yesterday’s post suggested, it is difficult to predict who will be high cost.  But patients with multiple, ongoing diseases or health conditions are almost certainly good candidates for this approach from a quality perspective even if money won’t be saved.  Another issue is patient engagement–not everyone who could benefit from these programs will agree to participate.  In this specific program, providers learned that participation could be increased by in-person introductions to the care coordinator by a physician.   According to the report, reductions of up to 20% in medical spending occurred for patients in the program at least 9 months and there was a modest improvement in health according to certain surveys.  I think these programs are a very good idea; but I also think it is unrealistic to imagine that they will save lots of money when the costs are taken into account.