Monday, March 17, 2014

Unnecessary Care, the 80/20 Rule and the Nuka System of Care

Last week, I wrote about the need to turn our current care management paradigm as it is related to the patient centered medical home on its head. I argued that we should focus more on those who don’t need intensive medical care, per se, but need help in other ways -- and who access the medical system because they don’t know where else to turn. That paradigm is based on the much touted“80/20 rule,” which holds that since 80 percent of costs are driven by the sickest 20 percent of people, cost-control efforts should focus on the 20 percent, as that will be more efficient and potentially more effective.

It pays (pun intended) to first review the 80/20 rule. The shortcoming of this rule is that it focuses on total costs and not on the subset of unnecessary costs. From my years in practice, and my years in medical economics and health policy, I know that the people who drive the highest percentage of unnecessary costs are in the 80 percent of patients who drive 20 percent of overall costs; the high-cost 20 percent are not, in most cases, incurring unnecessary costs.

Comparing two patients may help illustrate this. Consider the type of person I saw often in my gastroenterology practice. A person who is “health-anxious,” who is stressed at work, and who has perpetual stomachaches and constipation will often go to multiple doctors during the course of the year, have many tests and be on many medications, and may have pain severe enough to go to emergency rooms; at the end of a year, that person may easily cost the system $25,000 or more. Another person – this one with end-stage liver disease -- maybe in and out of the hospital with mental status changes, abdominal fluid and GI tract bleeding, until he or she undergoes a liver transplant; that person may cost the system $250,000 or more.

On whom should we focus? The one who costs $25,000 or the one who costs $250,000? When you actually look at both sets of medical records for signs of avoidable costs and waste in the system, you usually find that the lower-cost person --who is seeking care because of psychological and social issues as much as medical pathology --undergoes a higher percentage of unnecessary care than the high-cost person who is receiving needed high-intensity-of-service care. In aggregate, thankfully, there are many more patients with nonspecific abdominal pain and constipation than those in need of liver transplants, so the potential aggregate savings among the 80 percent is quite significant. The real answer however is to help both.  Help the bulk of patients who need reassurance, social and psychological support even more than they need diagnostic evaluations and help the smaller number of people who need excellent, well-coordinated care due to the severity and complexity of their diseases.

If the goal is to influence people toward better and less wasteful care -- while addressing their needs in the context of their values --it makes more sense to focus not just on the high-cost people, but also on those who are lower-acuity and often not suffering from diagnosable, treatable medical illness. Yes, we must help those with severe illnesses access the system in timely ways, get to the right physicians and facilities, and receive the right care without putting roadblocks in their way, as their care coordination needs are great. But even care for high-cost patients requires us to acknowledge that healthcare is not only about biology, but also about the psychological and social dynamics that are part of being human.

Two recent articles – one published in the International Journal of Circumpolar Health and the other in the Annalsof Family Medicine -- describe the Nuka System of Care in Alaska and give voice to the idea that focusing on people who are relatively healthy– the 80% and not only the 20% -- may be more productive in trying to decrease healthcare costs in the United States. In the International Journal of Circumpolar Health, Katherine Gottlieb states: “Southcentral Foundation’s Nuka System of Care is based on what customer-owners really want – a primary focus on building and maintaining relationships.”
Based in Anchorage, Alaska, the Southcentral Foundation Nuka System of Care is a customer-driven healthcare system that has arisen out of the bureaucratic morass previously centrally controlled by the Indian Health Service. Alaska Native people are the “customer-owners” of this system, and they have developed care based on physical, mental, emotional and spiritual wellness and dedicated to a team approach based on relationships rather than on regulation. It is most telling to review their concept of who controls healthcare, as this has driven much of their processes to improve care while decreasing costs. In the Nuka System of care, low acuity care is seen to be driven by patient and family decisions while very high acuity care is seen to be driven by the decisions that physicians and other health professionals make.  In other words, 80% of the people who access health care and use the health care system are making their own decisions with their families and friends while only the sickest people are under the control of medical decision making.  Acknowledging that patients and families make the bulk of healthcare decisions, especially when disease acuity is relatively low, is an important first step in understanding how best to decrease unnecessary care and thereby lower costs. 

Quoting the Alaska Health Policy Review in 2009 from their discussion of the Nuka System of Care;

“The current model that drives healthcare is very linear and assumes that the system and the experts in the system are the source of expertise and therefore the power and the structures are centered around them and their concepts. In medical processes the medical professional collects history, symptoms, and signs and comes up with a differential diagnosis. Then a lot of tests are ordered. The interpretation of these leads to a definitive diagnosis which leads to the prescribing of pills and procedures based upon protocols, standards, and best practices. Then they think they are finished.   
The reality is that the decisions that really determine illness creation and chronic condition optimization are mostly under the control of the individual – whether to pick up the pills, to take them as prescribed, to share them, to split them, to quit taking them, to use the oxygen as directed, to use the technology they are given, what they eat, how they sleep, whether they exercise, whether they smoke, whether they drink too much, how they handle frustrations and anger, etc.  …these are all under their control. These decisions are also hugely influenced by values, culture, religion, family, friends, internet, work, hairdresser, bartender, etc. We are foolish to think our short visits and medical paradigms will drive everything. This is a failed model.”   
Gottlieb reports that the Nuka System of Care has seen a 36 percent reduction in hospital days, a 42 percent reduction in emergency room and urgent care usage and a 58 percent reduction in specialty clinic use, while seeing an increase in customer satisfaction and a 25 percent increase in childhood immunizations. The Annals of Family Medicine reported improved access to care and decreased emergency room use, for all causes -- including for asthma, which was evaluated in more depth.  The bottom line? Relationships and a focus on all people -- whether their sickness is medical, social or psychological -- works to improve care and lower costs.

Yet the “failed model” – the one that focuses only on illness and also focuses on the sickest people -- is a model that the managed care industry and health plans have perpetuated with the rules, regulations and medical policies that are in place to “manage” medical care, especially the medical care of the small number of extremely ill people.

The work we do at Accolade, attempting to build trust with people early and when they are low-acuity, is the best way to fix the system, just as the people at the Southcentral Foundation’s Nuka System of Care in Alaska are doing. Both models understand that building relationships based on trust leads to significantly lower costs -- while maintaining the sacred role of care in our society and that approach is our best hope to decrease costs in a humanistic way in the United States. An 80/20 approach of trying to micromanage the sickest people will never be able to achieve as much.