As we move to value-based care models, where we place our focus becomes very important. With limited resources both in dollars and human capital, knowing where to spend our energy is dependent on knowing information driven by data. Sometimes dictum is driven more from thought than fact. We focus a great deal on those with multiple chronic diseases, and consider such individuals as the highly complex with high cost.
When we look at chronic conditions, it appears that whether or not a person has a functional limitation is the driver of cost. The Levin Group looked at the 2011 Medical Expenditure Panel Survey Data , adjusted to include the nursing home population (CMS, 2014; NCHS, 2013), and found that in the Medicare population:
- 48% had no chronic conditions or functional limitations; made up 11% of overall cost
- 36% had chronic conditions only; made up 31% of the overall cost
- 2% had physical limitations only; made up 2% of the overall cost
- 14% had both chronic conditions and physical limitations; made up 56% of the overall cost
Those with both chronic conditions and physical limitations made up 72% of the top 5% of healthcare spenders (NIHCM Foundation 2012, 2011 Medical Expenditure Panel Survey). These results show that it’s the addition of functional limitations on top of chronic diseases that is associated with higher costs.
This point seems to get missed when we talk about those with chronic diseases. We seem to forget that we should be really segmenting those with chronic diseases to those with and without functional limitations, and focus on those who have them. When we do this, we will also shift our focus onto those limitations, rather than just on their disease state. This finding should shift our focus onto the psychosocial axis more so than the biomedical axis.
Taking this one step further, when you look at the benefit of interventions and compare what it would look like in three different groups, age 65 or older with chronic conditions and functional limitations, all individuals with chronic conditions and functional limitations, and individuals at the end of life, the hypothetical savings based on impact of an intervention is $27 billion, $45 billion and $10 billion (Dying in America, IOM of the National Academies, 2015 pgs 524, 525). This speaks to the fact that our focus should be on all individuals with chronic conditions and functional limitations. The lesser impact of focusing on those at the end of life is due to the smaller size of that population and less time to intervene. Obviously it is hard to prospectively know who is in their last year of life, but this information is supportive of the focus on those that have both chronic diseases and functional limitations.
As we move to value-based care, the focus on creating models that impact the functional limitations of those we serve is paramount if we want to deliver on creating value for those that have chronic conditions.