Industry Voices—Chronically ill patients deserve a better care model

Skilled nursing facility
One-quarter of Medicare spending is devoted to patients during their last year of life. (Getty/Rawpixel)

Patients with multiple chronic conditions face many challenges, not the least of which is a healthcare system that inadequately addresses their unique and greater needs.

Mahesh Krishnan
Mahesh Krishnan, M.D.

Medically complex patients require longer office visits, multidisciplinary care teams and higher levels of care coordination. Yet we largely use the same model of care in place for treating the majority of patients who are relatively healthy. The result? Hospital admissions and ER visits that could be avoided, along with dissatisfied patients and rising medical costs.

In fact, 71% (PDF) of the $2.7 trillion spent on healthcare is for people with multiple chronic conditions. By 2030, almost half of the population—171 million Americans—will have more than one chronic condition.

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It’s time to forego the status quo and one-size-fits-all approach. The current system is failing our patients, impeding their quality of life and placing unnecessary burden on our healthcare system. We have a moral—and financial—imperative to do better for those who are the most vulnerable.

Existing pain points

Before we examine a path forward, it’s important to understand some of the reasons our current system fails medically complex patients.

  • They lack support. People with five or more chronic conditions use nearly six times (PDF) as many drugs and see a doctor three times more often than those with one or two conditions. That can be a lot to manage, both financially and logistically. Patients often need help getting to appointments, affording prescriptions and enrolling in community programs, including those that deliver healthy meals. However, our current system largely lacks the infrastructure to identify these needs, much less fulfill them.
  • Declines in health status are often addressed too late. Without regular monitoring and communication between office visits, patients’ health status can decline unnoticed, resulting in potentially avoidable trips to the emergency room, acute interventions and lengthy hospital stays. Moreover, even after they are discharged, 1 in 5 patients is readmitted within 30 days, and 1 in 3 patients is rehospitalized within 90 days.
  • Primary care visits are not long enough. The average primary care visit lasts just 15 minutes, so it’s not surprising that most patients—and some doctors—feel they don’t have enough time together. The problem is magnified when there are multiple conditions to discuss, as well as medications and further interventions.

RELATED: UnitedHealth's HouseCalls program hits 5M visits with a focus on preventative care

A different approach

Caring for high-risk, complex patients requires an entirely different care model—one that goes beyond typical disease/care management—to meet patients where they are with all the services they need. New models of care should include:

  • Systems that identify patients who are failing or at risk of failing. Certain factors—like recent hospital or ER admissions, the number and type of chronic diseases, and length of stay in an acute care setting—can help predict which patients are likely to require a hospital stay or other medical care.
  • Intensive home-based visits. Our predecessors were on to something with old-fashioned, black bag house calls, especially when it comes to medically complex patients. Not only are home visits convenient for patients—especially those who may have difficulty getting to a doctor—but when coupled with longer visits and the ability to integrate the patient’s surroundings, they also allow providers to better assess a patient’s health status and needed interventions, identify any home safety concerns and provide additional patient education.
  • Physician-led, multidisciplinary teams. Medically complex patients have a wide range of needs best met by a diverse care team. This collaborative approach not only helps improve clinical care but may also help address other factors—like stress, job insecurity and lack of familial support—that are often overlooked but strongly influence patients’ health. Multidisciplinary teams, with physicians as their quarterbacks, should be tailored to the patient and may include nurse practitioners, social workers, dietitians, behavioral health specialists, pharmacists, palliative care specialists and skilled nursing facility specialists.
  • Discussions about end-of-life care. Talking about death and dying can be difficult, but planning in advance can help ensure that patients’ wishes are followed, and this approach may reduce the costs associated with end-of-life care. According to the Kaiser Family Foundation, spending on Medicare beneficiaries in their last year of life accounts for about 25% of total Medicare spending on beneficiaries age 65 or older. Care teams that have spent substantial time with patients are well-positioned to help facilitate these discussions, which can help yield more realistic expectations about recovery, quality of life and a better understanding of patients’ wishes.

Patients with multiple chronic diseases will always require more resources than the general population. And while there is a lot of uncertainty in healthcare, there is no question that investing in these changes will help improve patients’ lives while reducing costs.

Mahesh Krishnan, M.D., is the chief medical officer of DaVita International and group vice president of research and development.