Care Management Requires Closer Attention

Consumers Cannot be Expected to Shoulder Burden Alone
Cindi Slater, M.D.

A new report out from the American Health Policy Institute and Leavitt Partners further quantifies what we already know: a handful of employees are responsible for the bulk of employers’ healthcare spending. The new report documented that among 26 large employers, 1.2% of employees are high cost claimants who comprise 31% of total healthcare spending.

                And yet high-deductible health plans may do more to bend the cost trend for healthy employees by reducing spending on items like pharmaceuticals and lab testing but not on inpatient care.

                The least heathy employees quickly blow through their deductible, and their health issues are so acute and their bills so large, they don’t shop around for care. So what is a large employer or any purchaser concerned about these high cost claimants to do?

                Consumerism in how we typically think of the concept but it doesn’t seem to be working.  For example, according to McKinsey, most healthcare consumers are not doing their homework – they aren’t researching costs or their choice of providers. And even for the handful that do use price transparency tools, new research shows this doesn’t result in savings.

                Fortunately, as the recent report explains, there are other strategies that can work. The report highlights data-mining, enhanced participation, wellness programs, care management, and biometric screening as some examples of strategies that can work. But we need to start by understanding the leading cost drivers in healthcare for these patients. It quickly becomes apparent there are several opportunities for intervention.

                 The first intervention is making sure high-cost patients have the right diagnosis to begin with. Misdiagnosis is more common than medical errors, resulting in an incredible amount of wasteful spending.

                One obvious strategy to address this is the use of second-opinion services, which are growing in popularity among large employers; according to Towers Watson, one quarter of employers plan to tie reimbursement to second opinion services by 2018.

                Once the patient has a correct diagnosis, the next opportunity presents itself: Taking a pause to discuss treatment options given the patient’s diagnosis and their personal situation.  During this step, patients need to understand the best-evidence treatment options, and articulate their personal values and preferences.

                Sometimes just a discussion about options is an opportunity for a patient to select a less invasive procedure. For example, as the report points out, Honeywell compelled employees to weigh their options before having one of five common high-cost surgeries. Honeywell realized savings of $5.6 million over the past five years.

                After discussing treatment options with the patient, the third opportunity for an intervention arises.  If the patient wants to move forward with the more invasive procedure or surgery, getting them to a high quality provider is the next step.

                What makes for a top-quality physician? One key metric is their experience and volume in performing certain procedures. In one large study reviewing the relationship of surgery volume and experience to physician performance outcomes, there was strong finding that increased experience and case volume is associated with lower mortality and reduced hospitalizations.

                As a final intervention point, we need to make sure the patient and their family/caregiver are getting the longitudinal support they need to cope. This is a way to ensure the patient gets access to the skills and resources available to them ranging from mental health and medication management to claims advocacy, benefit plan information, and access to caregiver and patient communities. Studies show patients with these social supports have better outcomes.

                For the past two decades, discussion about consumerism, skin in the game, and high deductible plans has been all the rage. And this strategy does have its place, encouraging employees who are mostly healthy make prudent care decisions. But we have spent very little airspace discussing what to do about the highest cost employees, how to manage their costs and get them the care and ongoing support that they need. That is now changing for the better and its time we had an in-depth conversation about what real care management means.

Cindi Slater, M.D., is the chief medical officer of ConsumerMedical. A version of this article originally appeared at The Health Care Blog.