A few weeks ago, New Yorker ran an excellent, must-read article by Dr. Atul Gawande entitled Hot Spotters with a subtitled question: Can we lower medical costs by giving the neediest patients better care? While physical therapy is not part of the article per se, there are lots of implications for us.
The article essentially highlights distinct efforts to save significant money in healthcare costs by focusing on a subset of patients-those that consume massive costs to the system thru hospital re-admissions, frequent ER visits, and excessive medication. While this strategy appears incredibly obvious, the article details the obstacles to successful execution which include correctly identifying these patients thru good data mining, the counterintuitive fact that these patients require more resources (particularly care coordination), unavailable reimbursement for such care, and the problems with disincentives for providing it in the first place (what hospital wants to be part of a movement to lower hospitalization?).
Dr. Jeffrey Brenner is highlighted in the article (and who is now one of my life heroes) as somebody making a difference in the troubled Camden, NJ area which ironically might just be the best place to receive healthcare if you have multiple chronic maladies. Through an uncanny ability to mine data, he found that between January of 2002 and June of 2008 nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. While his motivation was bent on helping people vs. saving money, he initiated The Camden Coalition which consists of primary care “supersized” in the form of extenders who assist with communicating to patients, tracking, counseling, etc. Bringing a customer service approach to the “least of these” patient almost all of which docs are happy to turn over patients they don’t want to care for has resulted in a 56% reduction in costs namely thru decreasing hospital re-admission and less ER visits.
A second effort for entirely different motivations is thru a company named Verisk (the Science of Risk) is detailed as well. Their role is to advise self-insured clients on ways to reduce costs and their approach is completely driven by data identification. They review a great example of how increasing co-pays actually increases overall costs even though overall medical utilization can actually go down. The reasons is simple-many retirees cannot afford the excessive co-pays for medication and doctor visits. Many of these same retirees have chronic conditions like heart disease and diabetes and when lack of compliance (dictated by hi copays) goes bad, the ER visits and hi dollar items go way up which nets to higher overall costs to the employer.
The implications for physical therapists are several. We can play a role as “hot spotters”. Many of these items have been discussed in this blog for years. PT’s are force multipliers. Every example on cost reduction includes using professionals and extenders in roles that they are best suited. Low back pain and metabolic disease are serious cost drivers. Through copay incentives (go to the PT and you don’t have one vs. a $50 copay for seeing an ortho doc) and care coordination (PT’s on the frontline under “supersized” care overseeing exercise and providing counseling). This can happen independent of a centric medical home model through the creation of a physical therapy accountable care group (another blog post for another day) which partners with those proactive entities really going after the 20% of the patients who are 80%+ of the cost. Who better to really bring customer service, evidence based practice, and hi touch clinical excellence to the forefront?
The best examples might be in our dealings with obesity and diabetes who are clearly heavy utilizers. When Dr. Gawande asks a patient who has made substantive changes resulting in less cost and drain on the healthcare system, the response is instructive for us:
“The couple credited exercise, dietary changes, medication adjustments, and strict monitoring of her diabetes.”
It’s time to start collaborating with these change agents before they engage community health workers who will replace us if we aren’t out in front on this one.
Thoughts?
larry@physicaltherapist.com
