A blog posted online on Tuesday on the Health Affairs website makes extremely important points about the landscape around care delivery and care management for patients with complex needs. Even its title says a lot: “Measuring What Matters Most to People with Complex Needs,” authored by Julie P.W. Bynum, M.D., M.P.H., an adjunct professor at The Dartmouth Geisel School of Medicine in Hanover, New Hampshire.
Dr. Bynum begins by noting that “Recent efforts to increase accountability for health outcomes and costs has put a spotlight on the immense challenge of providing high-quality and efficient care to people with complex needs, many of whom require inputs from both the medical and social care systems to remain at their highest functional capacity. People with complex needs often have functional limitations, such as the inability to effectively communicate, move about, or take care of themselves without additional help, and they may have behavioral health needs that typically incur high health care costs. Traditionally, these individuals have been a source of revenue for health systems due to the sheer number of covered services they receive. Yet, under new payment and delivery models, such as accountable care organizations and bundled payments, these people could be viewed as a serious financial risk because of their outlier expenditures and potential for poor health outcomes. Herein lies an opportunity to improve the management of care for this population.”
As Bynum continues, “The National Academy of Medicine’s (NAM’s) special publication, ‘Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health,’ serves as a primer for how health care stakeholders can use evidence-based approaches to effectively manage care for this population. How to measure quality and outcomes as models of care and policies are implemented, while also managing costs of care, should be further discussed. Accountability measures for this population are necessary to assess the effectiveness of health financing reform efforts.”
Bynum points out something that those caring for patients with complex needs already know: “People with high needs often have multiple chronic conditions and seek care in many different settings for which quality measures already exist. Yet, simply applying the myriad condition- and setting-specific measures separately to this population will not sufficiently inform whether care was high quality. That approach ignores the complex interplay of factors, such as degree of care coordination, quality of life, independence, and overall mental and physical status that drive outcomes and care experience for this population.”
Further, Bynum notes, “A conceptual framework of performance measurement for people with high needs must take the whole person into account. Referring to the high-need population as “patients” reflects our tendency to overlook needs that extend beyond the walls of the disease-based medical care system. If the social care needs of a person—such as food and housing insecurity, transportation needs, supports for daily activities such as mobility and personal care in the home environment or addressing behavioral issues—are not adequately met, they may in fact end up as “patients” in hospitals or clinics that are ill-suited to address the root causes of their decline. Without accountability metrics that incorporate gaps between medical and social care domains, it will be challenging to assess whether health financing reforms are effective or if they result in adverse consequences, such as delays and denials in care, for high-need individuals. Measures of unmet need for social care or caregiver burden are examples that capture core elements of any effective management team and may provide balancing measures for potential cost shifting from medical to social care providers.”
Dr. Bynum captures some of the core issues here with great insight and articulation. What’s more, we’re talking about quite a large number of people here. “As of 2014,” a 2017 RAND Corporation report authored by Christine Buttroff, Teague Ruder, and Melissa Bauman, notes, “60 percent of American adults had at least one chronic condition, and 42 percent had more than one chronic condition. NOTE: Percentages may not total 100 because of rounding. The prevalence of multiple chronic conditions is higher among older adults.” Those researchers note that “[C]hronic disease is a burden not only for these patients but also for the health care system overall. Those with multiple chronic conditions have poorer health, use more health services, and spend more on health care—trends that have been stable since 2008.”