It's well-established that a relatively small number of patients are responsible for much of the health care system's overall utilization. But as providers embrace a variety of care coordination measures and reimbursement changes to improve quality and reduce costs, the role of the patient is often hard to locate.

That's the philosophy of Douglas Eby, M.D., vice president of medical services for the South Central Foundation, an Anchorage-based nonprofit health care organization serving 60,000 Alaska Native and American Indians and a recent winner of the Malcolm Baldrige National Quality Award. The system, Eby says, focuses heavily on treating and building relationships with the patients who are most likely to show up in the emergency department or an inpatient bed — and ultimately drive much of the system's overall costs.

"There's a small segment which is burning through 20 percent of our society's wealth at a massive rate," Eby says. Those patients, Eby adds, "are the most needy, most dependent, most fragile and socially disintegrated people in society. We must meet them where they are on their terms and must fundamentally understand we're a service industry, not a product industry."

Meeting them on their terms, Eby says, means providers must find ways to communicate with patients as they live their lives in 2012. That means "cell phones, texting and phone calls ought to be core fundamental, high-volume" ways of communicating with patients, and "the office visit needs to become exception, not the rule."

The highest 5 percent of health care utilizers, Eby says, largely fall into three categories: patients with chronic mental illness, a "medically fragile" population comprised primarily of elderly patients with multiple chronic conditions and medication needs, and a group Eby describes as a "socially disintegrated," who tend to not engage in self-care, have few family resources and display dependent personalities.

The final group, Eby says, make up about 40 percent of the high-utilizer population, and the South Central Foundation works closely with these patients to develop care plans, navigate their care and build trust. For patients with significant mental health issues, a behaviorist often becomes the patient's primary care provider; for those with medically complex conditions, a nurse occupies that role.

Building trust takes a certain type of personality, Eby notes, and theSouth Central Foundation specifically looks for and trains clinicians with both the temperament and willingness to work with patients to change their health choices and present options for better choices.

"In the long term [health care] is about developing trusting, accountable, messy human relationships," Eby says.

Since 2008, ED utilization within the South Central Foundation's system has declined from 42.76 visits per 1,000 member months to 27.57 visits in June 2011. Inpatient admissions in that same time frame have remained relatively steady, from 5.72 visits per 1,000 member months to 6.10 visits. As an integrated system that relies heavily on block funding from the Indian Health System alongside substantial Medicaid and Medicare reimbursement, South Central can benefit from reduced utilization through its health care plan — an intrinsic advantage over providers that still receive most of their payments from fee-for-service transactions. But Eby points out that when the system first became engaged in this work over a decade ago, the system's funding sources, the nature of its patient population and remote location were cited as reasons why the new approach wouldn't work.

Ultimately, Eby says providers need to realize that while solutions to improving acute care delivery are vital — and where quality improvement methodologies like Lean and Six Sigma can help improve procedures, better outcomes and reduce costs — the truly significant areas for both improving outcomes and reducing costs lie in the realm of patient behavior.

"Health care thinks of itself as a manufacturing industry," Eby says. "[Health care] has fallen in love with Six Sigma and Lean and people think… somehow if you get the right pills and procedures that somehow health is going to break out. We fundamentally disagree with that."

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