Metrics details In his very influential article in the New Yorker, Atul Gawande shined a bright light on the small group of neediest patients who access the healthcare system extremely frequently. Even so, their health outcomes were notoriously poor, implying that the system could do a far better job of taking care of them. One of the ways to help accomplish this, Gawande suggested, was through care management and coordination, something that is, unfortunately, generally inadequate in American medicine, and likely even less available for this most vulnerable group of patients. Lee et al.
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Metrics details In his very influential article in the New Yorker, Atul Gawande shined a bright light on the small group of neediest patients who access the healthcare system extremely frequently. Even so, their health outcomes were notoriously poor, implying that the system could do a far better job of taking care of them. One of the ways to help accomplish this, Gawande suggested, was through care management and coordination, something that is, unfortunately, generally inadequate in American medicine, and likely even less available for this most vulnerable group of patients.
Lee et al. Unlike Gawande, these authors choose not to highlight these striking problems among this small group of patients, but stress instead the fact that these frequent users—which Lee et al. Because of this, they point out that even if it were possible to lower costs dramatically within this subgroup, our hugely bloated healthcare budget would not be greatly affected overall.
Although we believe that certain aspects of the methodology used in this study—and thus the precision of its conclusions—can be challenged, we have no doubt that the results are largely correct. Lee and colleagues confirm both that frequent healthcare users do very poorly despite incurring a disproportionate share of costs, and that a majority of expenditures nevertheless come from other sources.
They also identify various types of high-cost patients, and articulate that no single intervention will address their varied needs. If we want to impact overall healthcare spending substantially, therefore, we must, as the authors stress, look beyond the small group of hot-spotters. Is any of this a surprise? Who could doubt that no single intervention is likely to address the needs of all these high-cost patients? Indeed, we could argue that there are still other patients who do not fit neatly into Lee et al.
For example, patients who suffer acute trauma, patients who require emergency inpatient dialysis, patients with multiple chronic conditions, and patients with serious mental illness SMI or terminal cancer have all been identified elsewhere as high-cost frequent users. Clients receiving ambulatory cancer treatment, surgical joint replacement patients, and users of critical care, for example, are each clearly big-ticket users.
But worthwhile as it may be to identify such high-cost centers, we believe that any effort to address unsustainable healthcare spending also—and perhaps first and foremost—has to tackle, in a systematic way, the issue of waste. One-third of care provided in the U.
Outrageous administrative complexities, pricing failures, and business models that prioritize doing more and more result in unjustifiable waste. While this may not be done consciously, or on a patient-by-patient basis, it occurs systematically, because availability of care and use of resources are based in part on expected reimbursement.
What makes this particularly dangerous is that both too little care and too much care not only ultimately increase healthcare spending, but also directly harm patients. Finally, we caution against focusing only, or even primarily, on cost reduction.
After all, the primary goal of healthcare is not to save money, but to promote health and reduce suffering. Medicine should be a leader in addressing the medical, psychological, and social determinants of ill health. Many interventions, such as the Housing First program for homeless individuals with mental illness, may not be cost-saving, but may still have immense patient and societal value.
Frequent users have substantially increased morbidity and mortality, and thus are clearly not well served by our healthcare system, despite the excessive costs they generate. Historically, initiatives focused on hot-spotters have targeted patients based largely on medical service utilization, neglecting consideration of psychosocial service utilization and risk factors that contribute to vulnerability.
Care management and care coordination programs, if implemented effectively, can help address this. While this may ultimately prove to reduce costs, the primary value of such initiatives relates to engaging rather abandoning these patients, helping them navigate the healthcare system, and addressing both their medical and non-medical health needs. They can result in improved patient-oriented outcomes and enhanced provider experience, as well as cost reduction.
After all, by any account, our healthcare system has an egregious amount of waste, entailing care that is not value-added—and in many cases is harmful—to patients. At the same time, we need to acknowledge that many of the patients on whom we spend the most resources are complex, high-need, and vulnerable. Thus, even among this group, while cost-efficiency should never be ignored, the primary goal must be to provide the care best able to improve patient-oriented outcomes.
Fortunately, these two goals are by no means incompatible. References Gawande A. The Hot Spotters. New Yorker. January Accessed July 13, J Gen Intern Med. Google Scholar 3. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff Millwood. Google Scholar 4. N Engl J Med
The Hot Spotters
Goltigul A neighborhood couple, a physical therapist and a volunteer firefighter, approached to see if they could help, but police waved them back. At nine-fifty on a February night ina twenty-two-year-old black man was shot while driving his Ford Taurus station wagon through a neighborhood on the edge of the Rutgers University campus. In the Hot Spotter article Gawande writes about several innovative approaches to reducing health-care costs. This idea led to spottters creation of hhot Camden Coalition of Healthcare Providers. Gawande then describes the difficulties in implementing these and other innovative ideas on a larger scale, including opposition from insurance companies and the health-care lobby. Link to full text in the New Yorkert: Joel Greenberg has been a science journalist for four decades.
Based on the experience of a prior Allied raid and knowing that oil was vital to the German war machine, the High Command agreed. Herr General got his flak gunnery and fighters. When the Allies finally launched "Operation Tidal Wave" against the enemy on August 1, , the losses were horrific. While the military parallels may be a bit of a stretch for the peace-loving peoples of the Disease Management Care Blog, the question remains: should everyone get the same protection, or should we concentrate our special resources on those who are especially vulnerable? Gawande, using a common sense narrative laced with some rich anecdotes, correctly argues on behalf of the vulnerable. While they may be few in number, the non-compliant, disabled and socially isolated persons with multiple illnesses are the most likely to be victimized by a dysfunctional and inflexible care system. Gawande describes how the vulnerable can be protected with a high concentration of community-minded docs, nurses and social workers who can simultaneously reach out to these patients and save taxpayers millions of dollars.