Managing The Top 5% Expensive Patients, HBR Threatt_K

Managing The Most Expensive Patients by R.Pearl & Philip Madvig

                Approximately half of the dollars spent by the United States is to manage 5 % of the most acutely ill citizens.  Within that 5%, there are 3 groups: 1)those with chronic illnesses like diabetes, heart disease that require frequent MD visits or occasional hospitalizations, 2) those who suffer a significant illness such as cancer that may shift out of the cohort once treatment is done, and 3) those who have illnesses unlikely to improve and require expensive treatments over their remaining lives like chronic kidney disease requiring dialysis.  The authors point out that further examination of these groups is needed to look for opportunities to reduce this cost. Kaiser Permanente found that each of these cohorts are in a constant state of change, some people improve, stay stable, or may die from their illnesses. The acutely ill cohort are not an ideal target for cost containment or prevention as those are sudden illnesses that require life saving treatments. The severe chronic disease cohort also require routine frequent medical care for life sustainment. Kaiser Permanente (KP) found the most cost effective method would be to focus on the group with chronic diseases that can be improved and or complications to be avoided.  

                KP developed a model similar to the Primary Care Medical Home (PCMH). The PCMH Model is described as method of providing a team based care approach to primary care for patients across the health system¹. The model implements a care team made up of the physician, nurse, CMA, and usually a social worker. The KP model implies the PCMH model but involves the MD and a Certified Medical Assistant (CMA) as well as the use of technology support. The CMA screens results, triage calls, forms, symptoms in advance for the MD visits. The CMA also helps the MD follow-up with the patients at home with blood pressure checks, glucose logs etc. The technology component involves the use of the Electronic Health Record to provide up to date information on the patients. Patient wearable devices like FitBit or Apple Watch are able to transmit health data like oxygen saturation, heart rates. Video visits are key component as well via smartphones to be able to assess patients wherever they are. 

                KP has found as a result of this model reduced ER visits and hospitalizations and overall improved patient outcomes. KP patients in California have hospitalization rates of 0.7 days per patient per year compared to pre model implementation of 1.2 days per patient per year.  The rate is now less than half the national average for hospitalizations. KP also reports improvement in primary prevention: members in mid Atlantic and California have 28% lower risk of dying from colon cancer and 43% less likely to die from stroke compared to the U.S. population ². The KP Model has shown that it works, and also speaks to the cost effectiveness. Utilizing CMAs to help support the MD is less expensive than RNs which allows hiring of additional CMAs to a higher CMA:MD ratio to support patient care. 

It will be interesting to see if this model carries over to other health systems as both a cost effective and quality care model. The authors describe a very successful model that I feel has great promise. As a healthcare provider, we too are looking at utilizing CMAs especially as a bridge to the nursing shortage. I believe similar outcomes that KP found are reproducible in other care systems. However, not all patients or even providers see it as valuable. Specifically, as we try to bring more CMAs to our care team, we hear patient concerns of “I don’t want to talk to just a CMA, I want to talk to the doctor”, physicians may say “the CMA can’t help me complete all of my documentation or place orders”, and the CMA may say “It’s not my role to assess patients like this”. W heave struggled through this change in care redesign as patients and providers alike have had RN or NP support for all of this work. I know that CMAs who are engaged and included in the care teams with investment of being trained can absolutely run practices. Again, this is an excellent model that I believe is the future. However, change management techniques will need to be included to help patients understand the overall value as well as healthcare providers. 

1. Centers for Disease Control and Prevention. (2021). Patient-centered medical home (PCMH) Model. National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. Retrieved February 5, 2023  https://www.cdc.gov/dhdsp/policy_resources/pcmh.htm#:~:text=Print-,Patient%2DCentered%20Medical%20Home%20(PCMH)%20Model,care%20across%20the%20health%20system

2.  Pearl, R., & Madvig, P. (2020).  Managing the most expensive patients. Harvard Business Review, p. 2-9.