How Do We Bring Better Value to Seniors?

In the 2000 census the Medicare-eligible U.S. population totaled 35.1 million. By 2030 that same population is projected to grow to 69.7 million, and by 2050 to 81.9 million. The issues of improved health and longevity are further changing the equation. In the final decade of life, Medicare costs rise dramatically. The high costs associated with acute care and morbidity will simply be postponed to later in life as people live longer. Thus, there will be more elderly using nonacute Medicare services for longer periods. Most experts believe there is currently excess hospital bed capacity in the US adversely influencing current practice trends and holding back progress toward more efficient models of care. That said, bed shortages are projected by 2020 unless there are significant achievements made to provide medical care in outpatient settings, or build more beds at a projected cost now exceeding $100,000 per bed.

As one ages, the number of different disease states mount quickly. Today, Medicare members admitted to the hospital have a 71% chance of readmission within 12 months. There is a 19.6% chance of readmission within 30 days, and a 34% chance within 90. When patients are readmitted, follow-up care is found to be lacking in the previous 30 day period exactly half the time. And the average Medicare patient today has 5 chronic diseases, see 12 physicians, and have prescriptions for 50 different drugs each year. Most Medicare members will have one hospitalization during any 12 month benefit period. And the per capita cost in 2008 was $7,804 per Medicare member.

These numbers speak clearly for a need to have someone working alongside each senior to help coordinate the care associated with such mounting medical complexity. The incidence of depression is approximately 25% at any point in time with elderly members. And when present, members normally capable of managing their complex array of medications simply fall apart until the depression is treated or subsides. Furthermore,
the interaction between and among treatments is profound in elderly patients. For example, only 12% of diabetics only have diabetes. The remaining patients have varying degrees of renal insufficiency, heart disease, high blood pressure, cholesterol problems, and more. Medications used to treat the heart often worsen the renal problems, and vice versa. Specialists focused on single disease management often overload the patients with a total number of medications, causing difficult if not impossible management challenges. The complexity of it all results in poor compliance, interactions among medications, and more complications. It is a vicious cycle.

Today’s best practice calls for a careful discharge plan that encompasses medication review and simplification, patient education, and follow-up within one day of a patient going home. We botch this regularly in most hospitals, according to patient surveys post discharge. There needs to be another follow-up within one week of discharge, and a second follow-up within two weeks. The care transition coaches (if they even exist) are trained to identify red flags and work closely with each discharged patient depending on the particulars of each patient. Medical care follow-up with the primary physician coordinating the overall care is appropriate within the first week of discharge, assuming the primary care physicians can handle the case load. Complex patient situations often require a team approach consisting of help from mid-level providers, social work, Doctors of pharmacy, and high risk nurse educators. Today these resources are simply not sufficiently available to patients nor physician offices. The primary physician offices don't have the infrastructure to handle the case load. And either regular following of the patient within their home, or in an office setting is missed.

Every system is designed to perfectly deliver the results we see. To shift the way we currently care for our elderly members of society will require a careful look and coordinated team effort. The value equation is quality plus service divided by cost. The care paradigm required to better serve our elderly is also costly, but perhaps less so than the current paradigm. Given the consistent patient survey results of how much people hate to be hospitalized, certainly the quality and service should be greatly enhanced, even if cost remains high. As hospitals loose reimbursement for readmitted patients, more interest in models aimed at keeping patients home will be employed.  As with most complex problems, the solution usually depends on a champion.  Who will champion the effort required?  Who will coordinate?  Is the solution the primary medical home?  What should it look like?  Thanks for your thoughts.