Sunday, January 30, 2011

Atul Gawande's The Hot Spotters: Targeted Care Management Is Something New?

During World War II, Luftwaffe General Alfred Gerstenberg had a radical idea. Instead of spreading Germany's finite military resources in an attempt to protect every potential Allied bombing target, he argued that the Ploie┼čti oil fields in Romania warranted the flexible concentration of air defenses. Based on the experience of a prior Allied raid and knowing that oil was vital to the German war machine, the High Command agreed. Herr General got his flak gunnery and fighters. When the Allies finally launched "Operation Tidal Wave" against the enemy on August 1, 1943, the losses were horrific. 53 aircraft and 660 aircrewmen were lost, while the Romanian oil production actually increased in the weeks that followed.

Focusing resources for greatest effect is also the theme of Atul Gawande's article "The Hot Spotters" that appeared in the January 24 issue of The New Yorker. While the military parallels may be a bit of a stretch for the peace-loving peoples of the Disease Management Care Blog, the question remains: should everyone get the same protection, or should we concentrate our special resources on those who are especially vulnerable?

Dr. Gawande, using a common sense narrative laced with some rich anecdotes, correctly argues on behalf of the vulnerable. While they may be few in number, the non-compliant, disabled and socially isolated persons with multiple illnesses are the most likely to be victimized by a dysfunctional and inflexible care system. Instead of oil and war, it's millions of dollars in claims expenses and a fraying primary care safety net. Dr. Gawande describes how the vulnerable can be protected with a high concentration of community-minded docs, nurses and social workers who can simultaneously reach out to these patients and save taxpayers millions of dollars.

And yet, maybe the DMCB's wartime analogy is appropriate. Drawing battle lines at the end of his article, Dr. Gawande points out that "the new health-reform law's" targeted approach, could be "scuttled" by a sinister and unnamed "well organized opposition."

Really? "Where?" asks the DMCB. The "protect the vulnerable" approach has been the standard of care for commercial insurers for years. Population health management (PHM) vendors have been using health insurance claims in very sophisticated statistical algorithms (for example) to spot who is most likely to end up in an emergency room or be hospitalized. Once identified, just as The New Yorker article describes, professional care managers can coordinate with the docs and telephone or visit these patients in an attempt to reduce their risk. Since a single avoided hospitalization can save thousands of dollars, it's not long until the nurses can more than make up for their salaries - and then some - using the same common sense approaches described in Gawande's article.

Until the Affordable Care Act (ACA) was passed, there was no coverage by standard Medicare or Medicaid for care described in Gawande's article. Even with passage of the ACA, it will still not be explicitly covered, pending years of further study of various pilots by CMS. What's more, until the regulations were clarified, there was a good chance that the onerous Medical Loss Ratio (MLR) requirements of the Act would scuttle the commercial insurers' "protect the vulnerable" programs.

Sorry Dr. Gawande. "The Hot Spotters" didn't look in the right place and your discovery of targeted care management is more than a decade late. In fact, the focused and flexible application of resources to achieve the greatest impact has been around for some time for both good and bad. The one good thing about your article is that it may help CMS to catch up with both history and our patients' needs.


Andrew Brahe said...

I sense you would agree there is an acute need to provide care to the neediest patients, and the highest cost patients should be targeted. Targeting patients may not be new, but it's still a good idea.

A more appropriate example is in order.

Consider polio eradication efforts across India... Would you suggest that rural and isolated parts of india not be targets for vaccination? The efforts to eradicate polio globally are challenging, but the goal is clear and there is increasing willpower to meet the challenge.

Your arguments are conversation enders rather than conversation starters.

Gawande's article describes one physician who has already made an impact by volunteering his time to help the neediest of patients. Even if the impact is one patient, that is a start.

Jaan Sidorov said...

Andrew misinterprets my tone as a conversation stopper. The truth is that the conversation on focusing resources based on impact has not only been a m.o. in polio eradication, but in U.S. managed care. I fault Dr. G for not giving credit where credit is due and promoting the use of those lessons where they have ironically been ignored for too long: Medicare. Now THAT'S a conversation starter.