Just 1% of Americans are responsible for 22% of healthcare costs in 2009 according to the Agency for Healthcare Research and Quality (AHRQ). 5% accounted for 50% of healthcare costs. These findings mirror my research, something I blogged about previously here. In summary I have found that:
- about 1.5% of people consume roughly one quarter of hospital inpatient and day case resources
- 5% of people consume about 50%
- under 20% of people consume over 80%.
What a coincidence that the figures are so remarkably similar. You would think that the same knowledge would mean that we would have the same understanding of what to do in the face of such information. But it is here, the conversion of information into action, where our approaches diverge.
To begin with, the paradigm through which the system view this information is one of cost. The AHRQ report's findings can be used to predict which consumers are most likely to drive up health care costs and determine the best ways to save money, said Steven Cohen, the report's lead author.
Well this maybe true but not if, by viewing the problem as one of cost and saving money, we then refer to plausible but wrong headed approaches to "fix" them. We have become so seduced by the prevailing economic and management paradigm and its relentless focus on achieving efficiency through scale, specialisation, functionalisation and standardisation that we have dislocated ourselves from that most simple and humane characteristic - to understand and respond with care.
Apparently Steve is planning to look next at whether cost cutting plans make a difference. I would suggest he doesn't waste his time and will give him his answer now. They won't. If you try and manage costs, costs go up. Cost is in flow. A better way is to manage value for patients end-to-end over time. The results are incredible.
I reported before that in one experiment, not one person went on the prescribed pathway once we had understood them and the way they lived their lives. The chances of this being special cause for all of them is one million to one. And the hard facts? Well for that cohort of people there was a:
- 11% reduction in placements (nursing/residential)
- 16% reduction in acute admissions
- 42% reduction in community hospital admissions
In one stroke unit hospital running costs reduced by 23% (17% in the community) and performance has transformed from being of concern to one of the top performing in the country.
Through my experiments, by understanding the lives and wishes of people, ordinary people end up doing extraordinary things. They provide person shaped solutions. And the system benefits. We are still learning, but take a look at what understanding did for these 93 people involved in one experiment
12 prevented hospital admissions
25 reduced lengths of stay in hospital
6 prevented admissions to long term care homes
10 prevented carer breakdowns
29 prevented packages of care
18 reduced packages of care
7 prevented equipment provisions
And still too early to confirm, but in another experiment, what appears to be a 40% reduction in unscheduled care admissions.
And happier users and staff. No targets, no plans, no talk of integration or other such notions. No worrying about day case rates, ALOS, follow-up ratios. Just understanding people in the context of how they live their lives. Imagine doing that at scale.
From my experiments, wellbeing economies are blind to consumption information. Even if they had it they are systemically incapable of understanding how to respond to knowledge about people. This is a major driver of cost in the system. It is also a major reason for harm to patients.
We know who these consumers are. We know where they live. There is not even that many of them. We just know nothing about them as people. And all the time we offer them service and not person shaped solutions, knowledge of healthcare consumption is rendered virtually useless as the system is, itself, consumed by the chasing of targets, the delivery of the bottom line and delivering change at scale and pace.