"For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost.
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail."
This old proverb speaks clearly to the problem with healthcare in the U.S.: for want of the right care early on, we sacrifice people's lives and spend far more money than we would if we provided that care. We are losing the battle, and if we don't start paying attention to the basics, we will lose the war against chronic disease and crushing healthcare costs.
Lack of care comes at a big cost
When most people think about high healthcare costs, they think of drugs that cost $100,000 a year, unnecessary MRI tests or the wide variation in cost for the same surgeries. Some legislators and others want to focus on "free market discipline" to bring costs in line, using laser eye surgery as an example of how costs come down when consumers pay out of pocket. Besides being a lousy analogy (very little medical care is truly elective, and market forces work only when consumers can walk away) it focuses on a problem that is far down the list when you're looking for the root cause of high healthcare costs.
If we really want to bring down the cost of healthcare in the U.S., we need to focus our attention on the 20 percent of the population who drive 80 percent of the cost. The rest of us pay those bills, which are passed on to us in the form of higher taxes and health insurance premiums.
Most of the people in that 20 percent cohort have one or more chronic conditions. Cardiovascular disease and diabetes, which respectively cost $193 billion and $176 billion annually, are the two most costly and common diseases. Cancer care, by comparison, costs $157 billion per year. As of 2012, about half of all adults — 117 million people — had one or more chronic health conditions. One of four adults had two or more chronic health conditions.
Both cardiovascular disease and Type 2 diabetes are largely attributable to lifestyle. While there is definitely a genetic susceptibility that increases the risk for some populations, the overwhelming drivers of heart disease and Type 2 diabetes are poor diet, lack of exercise and smoking. If we are ever to bring healthcare costs down to a manageable level, we must prevent chronic disease by helping our patients change their diet and exercise habits and stop smoking.
But for many people, the horse is already out of the barn, and prevention is no longer possible. For these people, we need to be sure the horse doesn't founder for lack of a horseshoe nail.
ER visits and hospitals stays drive high costs
The biggest drivers of this cost are hospitalization and unnecessary use of the emergency room. People with poorly controlled diabetes and cardiovascular disease are more likely to acquire complications that require hospitalization, and patients without access to primary care are frequent ER users.
The numbers, of course, don't count the human suffering that results from these diseases, which is substantial. Nor do those numbers show why some people with these diseases have much higher costs than others. But a growing body of work looking at the social determinants of health points to non-medical factors as the reason that some patients use far greater resources. When the care we give ignores these factors, the results can be disastrous.
Let's say you have two patients, both with newly diagnosed with Type 2 diabetes. Both are women, 40 years old, and both have two children. Both presented with symptoms of fatigue and frequent urination. They have nearly identical HBA1C scores and are both 35 to 45 pounds overweight. Looking at their medical charts and basic demographic data, they seem pretty similar.
But things look different when you compare their non-medical data. Patient A has an income 600 percent above the poverty level, lives in a neighborhood with several well-stocked grocery stores and many safe places to walk. She has substantial savings for emergency needs, a college degree, good health insurance and prescription drug coverage, sick-leave benefits and extensive family support. She has a reliable car for transportation. She was diagnosed by her primary care physician.
Patient B has an income at about 150 percent of the poverty level, lives in a "food-desert" area, served mostly by convenience stores. She depends on public transit, avoids going out at night alone because her neighborhood has a high crime rate, and she has only a high school education. Other than her kids and an ex-husband, all her family members live 200 miles away. She is a contract worker and gets no paid sick leave. She frequently works overtime to make ends meet. She has no health insurance for herself, though her kids are covered under CHIP. She lives paycheck to paycheck, with only a small emergency fund. She was diagnosed at the ER, because she couldn't find a primary care physician with after-hours appointments.
Both of these patients are given a prescription for medication to bring down their blood sugar levels and a referral to a diabetes education class.
If you were to guess which patient would lose 20 pounds and bring down her blood sugar levels over the next 6 months, which one would you bet on? Which one would be more likely to have the time, energy and money to attend the diabetes class, change her diet and begin exercising regularly? Which one would be more likely to take time off from work for the next appointment with her doctor?
As a family physician, I've seen many patients who simply did not have the resources to manage their health well. If all we offer these patients are advice in the exam room, a referral for a class and a prescription for a drug, their health outcomes will be poor.
In our example above, Patient B needs more than a prescription and a referral. She needs someone to guide her and care about her, to help her understand her disease and to help her problem solve in a community that isn't set up to support her. If she doesn't get this support, she'll likely become a repeat user of the ER and is likely to suffer serious complications.
The consequences will be dire for her, her children and society as a whole. And all for want of a nail.
Intensive support is the nail that can make a real difference
But it doesn't have to be this way. Both private and public payers are beginning to realize that it is actually cheaper to apply intensive services to those patients who are at risk for serious disease than to treat the complications that ensue.
For example, in California, SynerMed, a Medicaid managed care organization with more than a million members, is working with a company called MedZed, which specializes in identifying and helping hard-to-reach and hard-to-manage patients. The company provides a network of primary care physicians, combined with a mobile force of nurses. The mobile care providers visit the patients at home and connect them with the PCPs via telemedicine.
Many of the patients in the project were frequent users of the ER or had multiple hospital stays, and their costs averaged more than $5,000 per month. Over four months with intensive support, ER visits and hospital admissions were cut in half and costs fell markedly.
"We build trust with our patients, and they learn to call us if they feel sick instead of going to the ER. We help them manage complex mixes of medical, behavioral and social problems. By going into the home we understand their challenges and we eliminate the barrier of getting to the doctor's office," said Neil Solomon, MD, FACP, co-founder and CMO for MedZed. Dr. Solomon is not only the CMO, he's also one of the PCPs who work directly with patients.
"We are currently growing the size of our panel. We are collecting better data to prove the value of our services. The current analysis shows before and after data, which isn't definitive," said Dr. Solomon. They are conducting additional analyses that include a matched control group to see if the utilization and cost reductions can be definitively attributed to the added services.
While the data is preliminary, the results are encouraging. If additional analysis confirms the value of focusing intense services on the difficult-to-manage outliers, and if the results can be duplicated elsewhere, it will shake up a lot of thinking about how to control healthcare costs. And if we can bring down the cost of care, perhaps we can change the national debate on health insurance coverage and how to pay for care.
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