HCLF: UChicago project to address high-resource patients

CHICAGO—With so much focus on increases in healthcare costs and other problems with medicine today, “it’s worth reminding ourselves of the incredible changes we’ve seen,” said David O. Meltzer, MD, PhD, chief of the section of hospital medicine at The University of Chicago, speaking at the Healthcare Leadership Forum on Nov. 14.

However, he said it is clear that other countries are doing comparable things with far less money. One single fact is most important, he said: healthcare expenditures are incredibly concentrated among a small fraction of patients. The top quarter of Medicare beneficiaries account for 85 percent of medical expenditures while the bottom 75 percent account for 15 percent of expenditures. Therefore, “efforts to control costs on the vast majority of people are not going to have big effects.”

While the Affordable Care Act has several large components, “it comes down to payment and delivery system reform. I’m not too optimistic about many of [the components].” For example, prevention is a worthwhile endeavor but there is almost no evidence that it will decrease costs.

Meltzer discussed the new economic theory of specialization and the adaptive organization perspective. Those who have high coordination costs as well as high returns on division of labor are in trouble, he said. Providers need to focus team care of simpler cases where it can be most effective because patients with many different problems require specialization.

Meltzer leads an initiative funded by the Centers for Medicare & Medicaid Innovation focused on Medicare patients at high risk of hospitalization. A personal physician cares for them not only when they are hospitalized, but also when they leave the hospital. That kind of continuous care is designed to improve outcomes and lower costs. The physicians have a panel size of just 20 patients rather than the more typical 2,000 to 3,000. They build interdisciplinary teams with the emphasis on the smallest appropriate team for any given patient.

The first couple of months, he said they spent mobilizing resources. The process is “the most complicated I’ve ever worked on,” Meltzer said, with hiring, credentialing, informatics, a new clinic, evaluation plan designs, and more. “We can have 40 people in a room discussing a patient’s problems which lets us come up with creative solutions which often carry over to others. We start to see patterns and can muster resources.”

The cost of the program isn’t much, he said, and should lead to negotiation of managed care contracts and shared savings.

Meltzer said he is “Intrigued by technologies but cautious. We need these tools just like we need specialized medications for specialized diseases. My guess is that unless we’re really smart about who we give those to, they won’t have much benefit.”

The Healthcare Leadership Forum was sponsored by ClinicalKey and presented by Clinical Innovation + Technology.