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.

What is Patient-Centered? – Ask a Patient!

A recent article and an accompanying editorial in the Journal of the American Medical Association reveal much of what I believe is both right -- and wrong --- about the direction of medical policy and medical care in these United States.

The article noted reveals that the patient centered medical home, which is the team-based approach of primary care in which primary care practices are paid more to coordinate patient care, does not produce savings or perhaps even significant improvement in the quality of care as was expected.  The editorial implores readers to carefully consider the results and avoid the conclusion that the patient centered medical home is not effective.  The author of the editorial then argues that the patient centered medical home, in order to be more effective, must better identify the really sick people and focus more on them.

I agree with the editorial that there is still promise in the patient centered medical home and that we must find ways to improve the function of that wonderful concept.  I am, however, troubled by the thought that focusing on sicker people, as the editorial suggests, through the patient centered medical home will lead us to the promised land of lower costs and higher quality. It seems like this arguments, and indeed the very structure of the medical homes as implemented, still tend to see people as the sum of their medical risks and illnesses rather than the person who has a life, and who may or may not have an illness. The patient centered medical home, by being focused on a physician’s office, rather than the patient’s home, may be missing the opportunity to try and enter in to a person’s life, even before they feel the need to see a doctor.  I wonder if we have to turn our current paradigm on its head, and focus on those who are not severely sick. To me, it makes more sense that people who are not suffering from diagnosable, treatable medical illness are the ones on which we should focus -- to try to help them avoid getting caught in the medical system that seems to respond to every unhappiness with a blood test, an imaging exam and a prescription.  What I learned while in practice was that most patients who seek medical care do so because:

1. They feel isolated and alone with their discomfort.
2. They are afraid.
3. They are hurting both physically and emotionally; however, the psychic pain is sometimes worse than the physical.

Some of these people have medical illnesses -- from upper respiratory infections to advanced cancer -- but they still come to the doctor for peace of mind and hope as much as they come for cure. When I was in practice in gastroenterology, I saw many, many people with abdominal pain, constipation, nausea and other symptoms. I sent many of them through evaluations that included imaging, endoscopy, and blood tests, even though I suspected that the best way to help them was to watch and wait. I knew, however that their fear and their perceptions of pain were such that watching and waiting would, in their mind, be tantamount to “doing nothing.” Usually the tests were unrevealing; however, they were also often reassured by the tests as that, in their minds, was “doing something.”  I thought that they benefited most by having someone to talk to about their symptoms and their life, but by the time they came to see me, especially as a specialist, they often could not hear me unless I “did something.” Testing became a way to share their concern and to help them feel listened to and less alone. The mindset by the time a person walks into the doctor’s office is that he or she wants a medical intervention, a medical test, a medical therapy -- whether or not the issue is medical, social, financial, cultural or behavioral, because in their mind, it is medical.

To find a way to decrease the over-testing and the overtreatment that is harmful and wasteful, we need to find people before they take that fateful step to visit the doctor. We need to enter their homes and their lives and help them realize that medical science cannot solve all of their problems. In my days in practice, I managed people on home nutritional support.  I found that when I went to people’s homes, I was able to better see into their life and understand how to help them without necessarily running a blood test.  In my current role, as I speak to people on the phone, I am struck by how often even on the phone, when people are in their homes, they are able to open up and talk about topics that in the sterile environment of the doctor’s office are impossible to discuss. 

In order to really foster patient/person-centered care, which should theoretically increase needed care and decrease unnecessary care, we have to ask two questions. They are:

1. Do people want a medical home, and if they do, what do people want from a medical home?
2. Why do people, who presumably do not like to be poked and prodded, do not like to spend money they do not have, and do not like to waste their time, receive -- and often seek out -- unnecessary care?

The answers may be so obvious that we are missing them. Here at Accolade, in our early years, we decided to ask people questions like this, in surveys and in focus groups. We asked what people wanted and needed as they accessed health care and health benefits. We learned people wanted a friend to stand by them. They wanted help through a difficult system, provided by someone they trusted. They wanted the proverbial place where everyone knows their name, even if it was virtual, over a telephone. They wanted a human being who knew them and their family and who understood what their values and concerns were. They really don’t necessarily want to be over-tested, but they wanted assurance that everything possible will be done if they are really sick -- and that the zeal to lower costs wouldn’t leave them sick and even at risk for death.

How to do this? At Accolade we do it with the Accolade Health Assistant®, who, for 60+% of the population we serve, will form a relationship with someone before he or she goes to the doctor. Community outreach programs with community health workers have the potential to help. Sometimes efforts as simple as community social centers with proper staffing can create atmospheres in which people helping people they know, takes the place of that unnecessary and often misguided trip to the doctor. Perhaps telemedicine systems allowing people the safety of talking to the doctor or nurse while they are in their own home.  I don’t expect there to be one answer that is right for everyone, but I do expect that the answer will be based on the power of human connections, more than on a medical model of disease intervention.

In many ways, the challenge to the patient centered medical home is that we really need person- centered holistic homes instead. We need safe places where people in need of support, hope, friendship, and help can turn to when they are in need.-- places to receive the kind of pointed advice and information that they need in order to avoid the risks and costs of being tested, prodded and poked unnecessarily at great expense to themselves and to society in general. 

Food, Relationships and Health: A Family History

As a Jewish-American, I am part of a culture in which food plays an integral role. In my family, however, it seems to go beyond the shared Jewish cultural history. A few years ago, I had the chance to stand on a hill in southern Poland, about two hours from Krakow, the closest major city, on the spot where my father lived as a child, and -- with his family -- ran a small restaurant and inn, providing shelter and food to the surrounding community. The Holocaust ended that endeavor. My father had, thankfully, moved along before then (tragically, not most of his brothers and sisters), but the family history stayed with him. In the United States, he, too, pursued the family food business, owning a small food store in New York City throughout his adult working life. I grew up bagging groceries and watching my father talk to the people in the store, understanding that his personal relationship with those people was as important as the food they were buying. When the larger supermarkets started popping up, my father would jokingly say that his pricing strategy was “nobody oversells me” -- meaning his prices were higher than larger stores. He knew he could not compete with a large chain that had buying power. But my father had the back of his envelope, on which he kept track of the interest-free credit he gave to people who needed food --a symbol of the personal relationships he had with his customers.

I watched and learned – and I continued the family tradition of interest in and support of food, except from a medical point of view. I ended up first in gastroenterology and then as a research fellow in nutrition, eventually becoming Board-certified in nutrition.  But I also continued another part of the family tradition – a belief that personal relationships were another form of nutrition. Nutrition for the soul, perhaps, but no less important than the food one puts into one’s mouth. I came to believe, both from watching my father -- and also from watching my mother prepare traditional food with love (from gefilte fish to pierogies) that food was part of the personal relationships that truly make life worth living.  I knew, from the way my mother invited total strangers into our home for dinner when there was a holiday or an occasion of any type, that there was a lot more to eating than the fuel the body needed, and that, in life, one should nourish others in many different ways.

My family history also led me to remain focused on the relationships I had with my individual patients. It further led to my career developing health strategies and managed care systems that were focused on individual relationships and individual needs, when I perceived around me a depersonalization of care systems.  When we started Accolade, it was out of this belief -- shared by all involved --that forming relationships with people, providing them with the nourishment of a friend and a helper when they were in need, was the right way to try and save our healthcare system. We have been proved correct, and with each person we help, I think about my father and my mother and what they taught me.

While my own career over time veered toward healthcare relationships and became less focused on food, my son, Rob Spiro, continued the family tradition of feeding others. He started a company Good Eggs which is also built on food and relationships. It fosters the nutrition and the personal, even emotional, aspect of good food being produced by people who care, and delivered (both literally and figuratively) to people who need that food. When he started the company, he called me and said, “Dad, I’m a grocer!” He has now taken his company to the point at which it is starting to change the paradigm of food production and distribution in ways my father, and his parents in rural Poland, would never have imagined. As I watched this video about Good Eggs, I could not help but see the unbroken link from my father’s family in Poland, to my father, to me and now to my son as we all try to feed the body and the soul.