November 23, 2009

Care management of patients with complex health care needs

Thomas Bodenheimer, MD, MPH, Rachel Berry-Millett, BA, all from the Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco write in this article that a high percentage of health care expenditures are associated with a small proportion of the population. Most patients in this high-cost group are Medicare beneficiaries with multiple chronic conditions, frequent hospitalizations, and limitations on their ability to perform basic daily functions due to physical, mental and psychosocial challenges. The growth in Medicare expenditures for beneficiaries with five or more chronic conditions is striking, jumping from 52 percent of total Medicare spending in 1987 to 76 percent in 2002. Given the 73 percent projected growth in the next 10 years of the over-65 population and the far higher prevalence of complex health care needs among this group, the costs of providing care for this population sector threatens Medicare's future viability.

For patients with complex health care needs, the issues of cost and quality are intertwined. For example, patients experiencing quality of care problems are likely to have more hospitalizations due to complications associated with poor quality of care. Therefore, days spent in the hospital per year is both a cost measure and a quality measure. High-cost measures such as hospitalizations, emergency department care and nursing home stays also may indicate poorer quality of life. Although complexity, vulnerability and age may not predispose older persons to receive poorer quality care, several studies provide evidence that patients whose care requires time-consuming processes such as history taking, counseling, and medication-prescribing do experience inadequate quality of care. Patients with high medical costs tend to lack trust in their physicians and have more negative assessments of the quality of the care they receive. A new source of health care, called care management, is a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively. This synthesis looks at the evidence and explores the potential for care management to improve quality of care and reduce costs for people with complex health care needs.