Dennis Y. Fong, M.D.

Population management can only go so far—the bottom 80% only spend 20%. The bulk of reducible costs actually lie with complex patients and their PCPs.

When complex patients’ acute events don’t become severe enough to map onto acute HCC conditions, total costs of care are unremarkable. When they do — when a scrape becomes septic cellulitis or when increased leg swelling becomes frank pulmonary edema— costs jump 4× on average.

Preventing that requires both:

• Patients seeking care early, even when symptoms seem mild
• PCPs maximizing resilience continuously, through regular whole-person tune-ups

It works — that kind of whole person longitudinal complex care took place in my PCP practice, and risk adjusted, my Medicare patients in 2010-2014 had 38% fewer hospitalizations and 39% lower costs than Medicare national levels.

This model can scale — but only if both patients and PCPs are incentivized. HEDIS and MIPS can’t address those behaviors. Payment reform can.

My two provider-side reforms (outcome-linked bonuses and complex-patient retainer fees) and my patient-side reform (the Straight Percentage Copay Model) directly incentivize the behaviors that prevent severe outcomes in complex patients — and the avoidable costs and suffering.

Incentives that prevent severe outcomes in complex patients — not just compliance metrics — is the key to disrupting the cost curve.