Part Three. Interview with Arnold Milstein, MD, Professor of Medicine, Stanford, and Co-Founder of Pacific Business Group and Leapfrog Group

Preface: Mercer Chief Physician and US Health Care Thought Leader Arnold Milstein, MD, has been appointed a tenured Professor of Medicine at Stanford University, where he will establish a new research center dedicated to accelerating innovations in health care delivery in the US and globally that improve the value of health care.

Because of its length, this interview will appear in four parts

The views of this interviewees do not necessarily represent the views of the interviewer.
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Q: In your work at Mercer, you described two innovations in peer-reviewed publications - travel surgery and the Ambulatory Intensive Caring Unit (A-ICU). Could you talk briefly about those innovations?

A: The idea behind travel surgery is pretty intuitive. We’re in a world where it‘s become easy to compare crudely the relative value of major high risk, high cost elective surgeries across borders. Patients and major employers are growing interested in travel to hospitals where complication risks and the total cost of care are lower, including surgery performed outside the U.S. As surgical outcomes become more validly comparable across hospitals and surgeons, travel surgery will slowly increase.

Q: And what about Ambulatory Intensive Caring Units (A- ICUs)?

A: One strategy for lowering costs is to provide much better quality care to the segment of health plan enrollees who are at the highest risk—that is, the 20 percent of enrollees who generate approximately 70 percent of a health plan's spending in a given year.

With funding from the California Health Care Foundation, I led a team of clinicians and engineers who designed a new primary care model called the Ambulatory Intensive Caring Unit (A-ICU). The model paired redesigned clinical teams with high-risk patients—those with severe chronic illness and/or socio-economic challenges that contribute to preventable health crises, high health care usage and very high annual per capita health care spending. Our strategy for lowering costs was to form specialized teams to provide much more intensive primary care to this 20% segment of health plan enrollees.

Our aim was to prevent high immediate "downstream" costs attributable to the limits of traditional primary care. The A-ICU team also intensively managed discretionary specialty care and ER care. We implemented three design features:

• "First Floor" care was provided by well-trained community health workers. These "health coaches," were supervised by A-ICU nurses and/or physicians. They help patients to manage their primary hospitalization risk factors 24/7.

• "Second Floor" care was provided by physicians supported by a team of medical assistants and nurses. The team uses an electronic health record, on-the-spot telephone consultations with specialists and selective in-sourced onsite specialist services to reduce the costs and increase the health impact of primary care visits. For example, a behavioral health specialist visits the second floor regularly to work with patients in need of such services.

• "Third Floor" care was careful management of specialist consultations including hospitalist care. Using data from a cooperating insurer, the A-ICU team selects a narrow referral roster of cost-effective and high-quality specialists with whom to coordinate actively.

We estimated that the A-ICU could reduce annual per capita spending by 15-30% net of its higher operating costs and substantially improve clinical outcomes and experience of care for high risk patients that consume almost 50% of total spending for populations under 65 and over 70% for populations over 65.

Q: Were you happy with the results?

A: Yes. Physicians’ operation of ambulatory intensive caring units (A- ICUs) was often inspirational. Implementation testing sparked additional organizational innovations. It showed that collaboration among American clinicians and engineers can create new care models that generate much greater value per dollar for their patients. Taking care of highly unstable sick patients with traditional care models is like trying to guard Kobe Bryant with a high school player. They can’t keep up with the rapidly shifting needs of highly unstable patients 24/7.