9. Complex Patients and their PCPs have been Overlooked for Cutting Costs

#WP_LCC #WPCR #APCCCare ↗ on LinkedIn

  Author’s notes

  1. Large numbers of PCPs can master complex care if the right incentives are provided.
  2. No need to wait for all the tools for PCP complex care to be built, with the right incentives the existing ones will be used more and new ones will be built.
Full post

Complex patients and their PCPs have been overlooked in the quest to cut costs and improve outcomes. Instead, administrative tools have been emphasized.

But the solution to costs lies with complex patients—those with multiple chronic conditions. They drive the predictable and reducible part of the high spending, not the unpredictable and irreducible part, like one-off accidents and catastrophes.

And the key to their costs is to prevent acute decompensations from becoming severe enough that they map onto acute HCC conditions. For example, keep acute bronchitis from becoming respiratory failure, dehydration from becoming shock. As I said in my previous post ↗, in years with no acute events severe enough to map onto acute HCC conditions, the total cost of care of the complex patient is unremarkable, but in years when there are such events, the cost on average jumps four-fold plus.

To prevent that happening, the complex patient must seek and their PCP must provide two critical parts of complex care:

  1. Early and effective care for acute events, no matter how mild;
  2. Prior maximization of resilience, no matter how frail— all along, the complex patient must have regular all-around checks and fine tuning to ensure maximum achievable resilience.

The model works—I provided that kind of complex care in my PCP practice, and risk adjusted, my Medicare patients in 2010-2014 had 38% fewer hospitalizations and 35% lower costs than the US average.

To incentivize the complex patient to seek complex care and the PCP to provide it is the most important measure for cutting costs. It is a law of economics that incentives drive behavior.

That means payment reform. My proposed outcome-linked bonuses ↗ and complex patient retainer fees ↗ will incentivize providers, and my Straight Percentage Copay Model ↗ will incentivize patients.

Administrative metrics like HEDIS scores are not going to dramatically lower costs any time soon—they are aimed at the broad population, and the bottom 80% majority only accounts for 20% of the spending. And capturing RAF to decrease MLR by increasing PMPM has been upended by HCC v28, among other things.

Time to focus on the complex patient and their PCP. It just might be disruptive.

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