The transformation of American health care delivery is on its way and it is not going back. Health systems are integrating with their physicians to create new clinical platforms capable of delivering higher value and greater accountability of performance.
More and more leaders are anticipating a future with real incentives to maintain the health of populations rather than just provide services to the very sick. While we are not in this future quite yet, we are anticipating it and preparing to meet it.
Heavy users, usually those with multiple chronic conditions, are a key target of the health care transformation that is under way, because heavy users contribute most to the high cost of health care. I call it the 5/50 problem: In any insurance pool the sickest 5 percent of patients account for 50 percent of the costs. Typically, those are patients who have multiple chronic conditions, or have cancer or major trauma.
In terms of identifying and managing these patients, we are beginning to understand hot spots (geographic concentration of heavy users in assisted living facilities and nursing homes as well as residential areas with extreme poverty and multiple social and economic deprivations). We also have increasing evidence of the effectiveness of medical home models and improved chronic care management techniques targeted at these patients. But we underestimate the degree to which the transformation of care must extend beyond medical care to social services, transportation, self-care and community-based support.
At the other extreme of the utilization curve, we are seeing a renewed interest in wellness, prevention and health promotion. The aroma of capitation reignites health system leaders' appetite for investing in health promotion, wellness and even public health initiatives, but our focus here is on the heavy users.
The field is moving, and innovations are on the way to make further gains if health reform goes forward as planned and we stay the course on payment reform and the redesign of the delivery system. Big data meets new thinking may be the key to unlocking this innovation and creating massively coordinated care.
"Big data" is a hot new term that refers to the massive data sets that are generated by all the activity in an increasingly digital world. Facebook's nearly 1 billion users generate untold terabytes of "Wassups" every single day. Similarly, in health care we are throwing off big data as we increasingly digitize the health care system. One analyst estimated that in 2011 alone, health care would generate 150 exabytes of information (by my calculation that is equivalent to 6 million times all the published works in the Library of Congress).
Global consulting players and industry gurus such as McKinsey and IBM are talking up big data, big time. McKinsey, for example, estimated that big data could create $300 billion in value by reducing health care spending by 8 percent. They argued that big data adds value to industries by:
- making information transparent and usable more quickly;
- enabling better performance measurement through digital capture;
- allowing finer grain segmentation;
- improving business analytics and decision support;
- enabling new products and services.
All of these changes are plausible in health care, and we should welcome them, particularly if they are applied to the challenge of predicting, analyzing, segmenting, treating and coordinating the care of the heavy users of health care.
Big data and the processing power of massive computers like IBM's Watson can help sort through tough analytical problems and provide guidance and support, maybe even replicating at scale and at speed the really tough work of clinical decision-making for those patients with multiple chronic conditions.
A good example of how big data can be put to good use in the service of accountable care is the excellent recent piece by fellow columnist John Glaser, "Six Key Technologies to Support Accountable Care." Glaser describes a set of financial and clinical smartware applied across the continuum of care to improve the targeting, treatment, engagement, coordination, follow-up and payment for a transformed accountable care system. Such technologies depend on big data to feed them.
Similarly, large health plans such as Aetna and OptumHealth (part of the UnitedHealth Group) and others are providing analytics and decision support tools to patients, providers and purchasers alike that rely on deep insights that only big data can provide. These tools can help target and coordinate care.
New Thinking beyond Medical Care
While big data can help us focus on the right answer for the right patients and support the institutional transformation to more coordinated and accountable care, perhaps a more important source of innovation will come when we change our mindset on the best way to frame the problem of heavy users and the care they need. Maybe medical care is not the only answer.
I have been impressed particularly by the story of CareMore, a little medical group in California that focused on multiply comorbid elderly patients enrolled in a Medicare Advantage model. CareMore does what the name suggests: It does indeed care more intensively for the patients it considers at risk; it has sophisticated and systematic practices for anticipating the needs and problems of these vulnerable patients; and it intervenes medically with more care before the seriously expensive acute care episodes ever happen.
CareMore's reputation and performance was not just built on execution of this medical care strategy, but also on its willingness to open its thinking to include transportation, fitness classes, concierge services, and building the trust and customer intimacy that is more the hallmark of an exclusive retail business than a health care provider.
More New Thinking
Many of the great innovations in managing heavy users will come from coordinated strategies involving community and social service resources. (We should not be surprised by this. After all, this is what Dr. Ed Wagner's Chronic Care Model, arguably the fountainhead of coordinated care and medical homes, called for in the first place.)
Here is one example of what I mean. On a recent visit to a community in the Central Valley of California, my wife and I happened to be on a tour of medical hot spots that had been identified by an earnest young assistant city manager, after he was inspired by a TV documentary of Dr. Atul Gawande's descriptions of hot spots in Camden, N.J.
The city manager (armed only with a little data on 911 medical calls to the fire department) had identified about a dozen hot spots in his city that accounted for a significant part of the 8,000 fire department emergency callouts, at a cost of $4,000 each. One major hot spot was an assisted living facility whose idea of assisted living seemed to be to call the fire department for assistance when patients had any sign of trouble.
Similarly, we toured hot spots where fire trucks became taxis, where asthma outbreaks occurred in apartments that violated building codes, and so on. When my wife (a former ER nurse and systems analyst) asked, "The fire department went out on 8,000 medical emergencies, but how many fires did you have?" The answer was 10.
Our valiant assistant city manager has begun to identify how simple, nonmedical, non-health care interventions — like seniors' transportation services, cooperation with and support of landlords on mold remediation, help with job counseling and social service support programs — could save millions of firefighting resources. He doesn't have access to the records of Medicaid, Medicare or the city's hospitals and clinics that incurred the costs and had the unpaid or underpaid bills that resulted from the emergency department visits, many of which were true emergencies I am sure, but many of which were not.
If we meet people in their lives, not just in our facilities; if we focus particularly on poor people, sick people, the disabled, the mentally ill and the economically vulnerable; if we meet them then and there with what they need, maybe we can avoid massive, redundant medical costs borne of systems failure.
If we can apply sophisticated analytics and big data to this cause, then maybe we can have Massively Coordinated Care that is better for the heavy users, more effective, more humane and much, much less expensive, as CareMore has shown.