Thursday, February 24, 2011

Who needs intensive primary care?

In almost every large hospital in this country, there are at least two types of patient beds: regular and intensive care. Intensive care beds are designed for the sickest of the sick - patients who require continuous monitoring, specialized respiratory or cardiovascular support, the most knowledgable consultants, the most powerful drugs. Intensive care units (ICUs) have long been accepted as a necessary innovation in inpatient care, leading to better outcomes for patients than would have otherwise occurred if they were treated with a hospital's "ordinary" resources.

In his recent New Yorker article, "The Hot Spotters," Harvard surgeon Atul Gawande reviewed medical outreach programs to the sickest, costliest five percent of outpatients, programs that he termed "intensive outpatient care." It was the first time I had seen this term, and it got me thinking. While hospital ICUs have primarily become the domains of subspecialist critical care physicians (often called "intensivists"), intensive outpatient care's natural leaders are primary care clinicians. So when Gawande described family physician Jeffrey Brenner's innovative program to improve care coordination and reduce hospitalizations in Camden, New Jersey, what he was describing was really intensive primary care:

If he [Dr. Brenner] could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city’s health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients.

As Josh Freeman pointed out on his blog Medicine and Social Justice, the reason that attempts to constrain health care spending by increasing co-payments for drugs and other services (described by supporters as giving patients more "skin in the game") inevitably fail is that these interventions target the 90 percent of patients who hardly utilize the health care system at all. Meanwhile, the 5 to 10 percent whose illnesses drive health care expenditures - the sickest of the sick - cut back on essential care, their conditions spiral rapidly out of control, and hospitalizations and costs keep rising.

The programs described in Gawande's New Yorker article aren't the only models of intensive primary care out there. Some have been around for quite a few years, mostly targeting elderly patients with multiple chronic conditions and funded through Medicare. These include the national Program for All-Inclusive Care for Elderly (PACE), covering more than 23,000 people in 29 states; Johns Hopkins University's Guided Care nurse-coordinator program; and old-fashioned house calls, which family physician Steven Landers has dubbed "The Other Medical Home" and believes are key to revitalizing the specialty of family medicine.

Intensive primary care isn't for everyone, of course. For one thing, it costs too much. And for most patients with acute or simple health conditions, the 15-minute office visit model still works just fine. Intensive primary care should be reserved for the sickest of the sick - patients who require frequent monitoring, specialized social support, the most knowledgable consultants, the most complicated drugs. So how can we design criteria to identify patients who should be transferred from regular to intensive primary care - criteria that will improve the health of the sickest patients, be acceptable to payers, and result in lower health care costs?