Costs - The Frail and Elderly: The Costly One Percent

One Percent of Patients Account for 20 Percent of Costs

This day I spoke to John Shard, MD, 66, who lives in Lakefield, Connecticut, a small hamlet tucked in the Northwest corner of Connecticut.

Shard heads up an organization Enhanced Care Initiatives, or ICI. Through contracts with managed care organizations, such as Tufts Health Plan and HealthSpring, Inc., a small managed care firm in Nashville, ICI provides and organizes care for frail and elderly patients, mostly over 75 and mostly with multiple chronic diseases.

Medicare, Medicaid, and health plan data indicates these patients, who represent one percent of patients, account for 20 percent of health costs. Four percent of these patients represent 40 percent of costs. Many fall through the cracks of traditional care. They tend to be socially isolated and depressed.

Shard says his organization seeks to establish ongoing relations with these patients. They do this through nurses, care coordinators, and regular community meetings bringing the frail and elderly together to discuss problems and solutions. These meetings break the isolation cycle and lift many patients out of depression. Many sessions open with jokes, which the patients bring. For subject matter, the meetings feature practical things patients can do to improve their health status, like simple exercise or dietary changes.

Another key ingredient in ICI’s success (it decreases hospitals by 33% and emergency room visits by 25%) is a meeting between ICI nurses and the patient’s doctors. Doctors respond positively to these meetings, which serve as a powerful intervention and improve accounts dramatically. The elderly, it turns out, aren’t helpless and passive. Given a modicum of attention, they adsorb advice greedily and are highly educable. ICI and the doctor together become potent advocates for the patient.

The nurses have a laptop containing an electronic medical record with clinical guidelines. With the EMR, ICI can track and document what nurses are doing and how the patients are responding. The ICI program is strictly a “hands-on” operation and depends heavily on personal contract, rather than telephonic follow-up, which many competing disease management firms emphasize.