The Power of Clinical Strategies to Reduce Costs: The Unexploited by 0m63vv


									The Power of Clinical Strategies
     to Reduce Costs: The
  Unexploited Opportunity for
States as Healthcare Purchasers
           Bruce Amundson, MD
       Community Health Innovations, Inc.
There are two components of population-based initiatives: (1) wellness and
   prevention efforts aimed at healthie2r lifestyles and reduced costs over the
   long-term, and, (2) clinical approaches to deal more effectively with the
   current disease burdens of the population. This latter effort can reduce
   costs over a shorter term, and will be the focus of my remarks.

The central argument: The greatest opportunity to reduce
  health costs is to change the way we provide care to the
  sickest, most complex and most costly segment of the
  population. There is wide-spread consensus on this
  perspective among clinical leaders nationally.

Why is this and how can it be accomplished?

  Health Costs for any Insured Population

% Insured Pop.      % of Expenditures

                   1970    1980   1990

Top 5%               50      55     54
Top 10%              66      70     68
Top 30%              88      90     88

The Clinical and Financial Profile of this 10%

Financial: depending on whether the insured group is made up of
   Medicaid, Medicare or commercially-insured individuals, the cost
   ranges from $30,000 to $150,000 per enrollee per year! (For
   commercial groups the typical cost range is $35,000-45,000 per

Clinical: These individuals have complex health profiles, usually
   representing one or more serious medical problems, accompanied
   by behavioral issues (often depression), and commonly in a
   framework of serious family problems. This is particularly the case
   with Medicaid populations.

YET: 15 years into heath “reform” we are not dealing differently, in a
  population-wide manner, with this 10%, than we were before.

      Bridging the Knowledge-Implementation
There is a huge gap between what we know how to do, what is being carried out in some places, and what is actually
    going on with these complex enrollees in most state-sponsored health plans.

For example, many Medicaid programs have focused on “Primary Care Case Management” efforts where Primary Care
     Physicians are given extra reimbursement to coordinate the care of patients. While a first step, the clinical
     complexity of many/most Medicaid enrollees makes this role unrealistic. It is a relatively weak “care management”
     strategy compared with strategies such as:

   1. Multidisciplinary healthcare teams composed of nurse case managers,
      mental health professionals, social workers and health educators. Working with
      primary care physicians, they are able to ensure all health problems are
      simultaneously and comprehensively addressed by bringing the broad range of
      necessary clinical skills to the work with highly complex people and problems.

   2. Case management: nurses trained in the role of helping individuals get the support and
      assistance needed to address their health problems and navigate the non-systems.

   3. Disease management: programs to assist patients in better managing specific diseases.

   4. Integration of medical clinicians with behavioral clinicians, in the same locations. This assures
      optimal and equal attention to physical and mental health problems, with much better results. This is the opposite
      of “carve-outs” which fragment care and have less impact on cost containment.

   Sample Results from Better Care Mgmt.

  Utilization of a Multidisciplinary Team with Medicaid Pts.
        (per 1,000 enrollees per year): 1993 vs 1995

       Pre-Care Mgmt Data            Post-Care Mgmt Data

In-pt. Admits        201                     97
In-pt. Days          817                     212
ER Visits            859                     311

  The work of the health teams was focused on the sickest 10% of
  enrollees as determined by health risk assessments upon their entry
  into the health plan.
           Sample Results (con’t.)

 Healthcare Team impact on hospital utilization
    by 65 complex patients, 2003, Maine

            6 months before          6 months
          team management        after team mgmt

Hosp. admits        39                  15
Hosp. days         137                  54
ER visits           26                  21

                 State Policy Options

1.   Purchasing strategy: require that contracting insurers
     develop specific, state-of-the-art care management
     services such as those discussed above.

2.   Further, require that these services be decentralized
     into communities where the state has enrollment levels
     that are large enough to justify the clinical programs.
     This is in contrast to the approach of many insurers
     currently where clinical staff (case managers, etc.) are
     housed centrally in the urban offices of the insurers.
     Experience has made it clear that, to be effective, the
     clinicians need to be in the communities where both
     the enrollees and their physicians reside.
           State Policy Options (con’t.)

3.   State purchasing programs (Medicaid; state
     employees) could directly work to establish care
     management services in communities across the state,
     where ensured population sizes warrant. These
     clinicians could then work with health plans and/or
     physicians in the networks that care for state-
     sponsored enrollees.

     Each of these potential initiatives is designed to
     expand the capacity and sophistication for care
     management to improve care and reduce costs for the
     most costly enrollees

          Observations and Summing Up

1.   Most states are a decade behind in implementing contemporary
     clinical care systems for the populations for whom they purchase
2.   States as purchasers have an immense potential to leverage
     change and a severe need to modernize care systems to deal
     with the massive cost issue for state governments.
3.   Ensuring the presence of more state-of-the-art care management
     systems would be highly relevant for: Medicaid families, special
     populations with complex health needs (DD, disabled, etc.),
     nursing home and potential nursing home occupants, and state
     employees. The opportunities to reduce costs are huge.
4.   Policy makers should support and empower their health program
     administrators to innovate and lead in the development of
     initiatives that can both improve care and reduce costs (an
     attractive mix, since the improved care is what reduces costs.)


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