Ian Morrison

The transformation of American healthcare 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 healthcare transformation that is underway, because heavy users contribute most to the high cost of healthcare.  I call it the 5/50 Problem:  in any insurance pool the sickest 5% of patients account for 50% 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 about Hot Spots (geographic concentration of heavy users in assisted living facilities and nursing homes, and those residential areas with extreme poverty and multiple social and economic deprivation).  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

Big Data is a hot new buzzword that refers to the massive datasets that are generated by all the activity in an increasingly digital world.  Facebook’s nearly billion users generate untold terabytes of “Wassups” every single day.  Similarly, in healthcare we are throwing off big data as we increasingly digitize the healthcare system.  One analyst estimated that in 2011 alone, healthcare will generate 150 exabytes of information (by my calculation that is the equivalent to 6 million times all of 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 spending by 8%.  They argued that Big Data adds value to industries in five ways:

• Makes information transparent and usable faster
• Enables better performance measurement through digital capture
• Allows finer grain segmentation
• Improves business analytics and decision support
• Enables new products and services

All of these changes are plausible in healthcare 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 healthcare.

Big Data and the processing power of massive computer’s 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 knowledge 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 on the Six  Key Technologies to Support Accountable Care.

(http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=8910003663)

John 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 are dependent on Big Data to feed them.

Similarly, large health plans such as Aetna amd Optum (Part of United Healthcare 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 how best to frame the problem of heavy users and the care they need.  Maybe medical care is not the only answer.

I have been particularly impressed by the CareMore story.  A little medical group in California that focused on multiply co-morbid elderly patients enrolled in a Medicare Advantage model.  CareMore does what the name suggest:  they do indeed care more intensively for the patients they consider at risk, and they have very sophisticated and systematic practices for anticipating the needs and problems of these vulnerable patients and intervene medically with MORE CARE before the seriously expensive acute care episodes ever happen.  But CareMore’s reputation and performance was not just built on execution of this medical care strategy, but their willingness to open their 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 healthcare provider.

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 exposed to and inspired by, a TV documentary of Atul Gwande’s descriptions of Hot Spots in Camden New Jersey.

The City manager (armed only with 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 call outs 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 were in apartments that violated building codes, and so on.  When my wife, (an ex ER nurse and systems analyst) asked the question:  “The fire department went out on 8,000 medical emergencies, how many fires did you have?”  The answer came back, “10”.

One valiant assistant city manager, has begun to identify how simple, non-medical, non-healthcare interventions like seniors transportation services, cooperation with and support of landlords on mold remediation, on job counseling and social service support programs, could save millions of firefighting resources.  He doesn’t have access to the records of Medcaid, Medicare, and the City’s hospitals and clinics who incurred the costs and had the unpaid or underpaid bills that resulted from the ER 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 born 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 Care More has shown.

Ian Morrison is an author, consultant and futurist based in Menlo Park, Calif. He is also a regular contributor to H&HN Daily and a member of Speakers Express.