The medical community was surprised and disappointed by the recently reported results of a randomized controlled clinical trial of the “hotspotting” program created by the Camden Coalition of Healthcare Providers. The ex post facto analysis pointed to system-level complexities as being barriers to the expected study outcomes of targeted interventions.
However, the study revealed two fatal flaws, and they offer a profound lesson to all of us working to improve the capacity of our systems of care to improve the quality of health of individuals and communities.
The first flaw was the use of utilization as a patient selection model. Utilization represents an economic imperative that ultimately accrues benefit to payers, not patients. Yes, being in the hospital is not good for patients, but should that really be the leading indicator for a study of selective resource-allocation. Hotspotting based on utilization isolates patients from the broader context of their health and makes it hard to evaluate the value of the program design to individuals and communities. As noted by Drs. Ruth Stein and Dorothy Jessop in their groundbreaking work on chronic illness, neither utilization nor diagnoses truly represent a patient’s complexity. Two patients with CHF may be in very different ‘condition’ and may have dramatically different determinants of their current state. We need to be mindful of allowing those members of the healthcare ecosystem whose values do not always prevail towards the patient to exert disproportionate influence on our efforts to design and evaluate how we care for people.
The second flaw was grounded in medicine’s natural tendency towards reductionism in our approach to the design and evaluation of model of clinical care. The study design focused on only one arm of the Triple Aim and the population served was not clinically heterogeneous enough to demonstrate the power of ‘resource-managed care delivery’ to effect per capita costs. Reducing utilization costs does not reflect the capacity of resource-managed care delivery to improve the patient experience of care or the health of populations, which may themselves reduce per capita costs across a high-need community.
In my experience as the CMO leading a national primary care practice and ACO exclusively serving medically complex adults with home-based primary care, when you stratify resource allocation based on utilization, you instantly exclude many patients from your population who could benefit from intensive team-based care and organically shift the cost curve while improving (or sustaining) their quality of health. Even when you hear the phrase ‘rising risk’, you need to ask the question: Risk of what? It’s usually risk of being expensive.
Our approach, in a CMS demonstration project of our model, assigned a care coordinator to every patient and, rather than stratify based on utilization-related risks, we applied a universal ‘risk/condition’ assessment to all of our patients. This allowed us to more accurately determine the requirements of time and attention by member of their care team to improve/sustain their health. Resources were not allocated based on patterns of utilization or specific diagnoses, but on the current state of the patient’s “condition”. This model resulted in the highest level of performance among the 12 other practice networks in the demonstration, and became the basis for our top-ten performing ACO a few years later.
In 1977 Dr. George Engel raised the specter of reductionism in medicine and advocated for a more inclusive scientific model, if, “physicians in the future are to apply the same scientific rigor to the approach and understanding of patients and their care as they customarily apply to the diagnosis and treatment of disease”. His recommendations were prescient, yet we have done little substantive towards their realization. Imagine what the current state of our capacity to improve the quality of health of individuals and communities would look like today if we had taken Dr. Engels advice to incorporate behavioral dimensions and social factors into the mental model, and organizing principles, of care.
While Dr. Engel was attempting to operationalize systems theory for medical practice, he was describing a putative view of the intersectionality of science, behavior, economics, social policy, and environment as a way to understand the weaknesses and failures of our systems of care.
Originating in black feminism, intersectionality is a framework to discern and clarify how the relationships between social identities (including but not limited to race, age, gender, class, and sexual orientation) are integrated in their contribution to systemic oppression and discrimination experienced by individuals and groups. Intersectionality helps us understand how overlapping categories of identity impact individuals and institutions and provides an integrated framework to account for them when designing policies, programs and platforms to promote equity. Intersectional forces exert powerful effects on health status of key communities; social identity influences determinants of health, treatment bias, disparities of access, and healthcare economics.
However, there is also value in viewing our systems of care through an intersectional lens, to examine and incorporate other intersecting forces — such as academic privilege, research funding, corporatization — that have protected the dominance of the model of biomedical reductionism and support or suppress ideas in order to protect (and impede the forces of change on) the dominant structure of medical education, medical publishing, and healthcare’s clinical operating model.
As Dr. Engel also noted back in 1977 “…medicine’s crisis derives from the…adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry…how (we) conceptualize disease…determine(s) what are considered the proper boundaries of professional responsibility and how they influence attitudes toward and behavior with patients.” (and curriculum and policy and research).
Healthcare economics — financing, cost control, and payment reform — dominates our national conversation and has been the primary driver of care delivery redesign, especially around the concept of ‘value-based care’. However, “value” is contextual, and currently grounded in a financial calculus of efficiency, risk-reduction and managed resource utilization. Value-based payments are either embedded in capitated fees or tied to utilization-associated metrics and quality measures with known health-economic value.
The responsible evaluation of a framework for resource-managed care would ensure that every member of a targeted population would be afforded the same opportunity to assess their health status, and allow for a rational and individualized approach to intervention design and resource allocation towards healthcare’s social imperative while ensuring a concordant, harmonious experience for the patient.
Dr. Merahn is currently Chief Executive of Union In Action, a 501(c)3 public charity whose mission is to enhance the capacity of our systems of care to improve the quality of health of individuals and communities using the principles of integration, collaboration, and orchestration.
For a white paper on universal risk/condition assessment, click here