As I sit here starting to write this post, I am thinking that it might not be perceived so favorably.
When involved in healthcare, the first commandment is “Do no harm,” and the overlying ethical position is to provide quality of care to all patients, no matter their station in life or circumstances.
But in thinking this through, we have to realize that one solution doesn’t fit every patient’s needs. What engages me, may not and probably won’t engage my wife, mother or father. Each person has their own individual way that they personally want to be engaged, some involving lighter touches utilizing solutions and technology already in their lives and others may need a more iron fist, restrictive regimen to keep them compliant (that won’t work with me). So, in my endeavors throughout the past 9+ years in Mobile Healthcare, I have personally concentrated on reducing healthcare costs in the patient population of the 20% that consume 80% of our healthcare costs today. I truly believe that is where we get the biggest bang for our buck.
I’ve talked a lot about the 20/80 rule in healthcare (the Pareto Theory) over the past years:
20% of people consume 80% of the healthcare costs (close enough)
20% of the effort yields 80% of the results
Patient engagement is 20% technology and 80% psychology (at least in my thinking)
My viewpoints have been somewhat radical from the sense that I am concentrating on “stabilizing” the health of a patient (in that 20% that consume 80%) in order to avoid hospitalization or exacerbation of their disease, thus reducing healthcare costs. Critics have suggested that I am dealing too far down the line, that efforts should be concentrated way before a patient develops a chronic illness (or at least trying to head it off) by investing in wellness and education of the patient. They contend in my world, I am closing the doors after the horse is out of the barn. I totally agree we should invest in preventive medicine and head the chronic disease off, in fact we should start back at genomics, but once the horse is out of the barn, are we just going to let it run free, or at we going to try and capture and control it and bring it back to a safe place?
We have to be realistic about what we are truly trying to accomplish in healthcare today.
I am guessing that it really comes from the perspective of whether you are a patient, provider or payer. A patient wants the best care possible. A provider wants to give the best care possible, and a payer wants the best care possible for a patient, but at the same time needs to control the economics of the situation. We have to be realistic about what we are trying to achieve. In my world, I am trying to deliver the best quality of care for the patient, but at the same time reduce healthcare costs. A lot of people are engaged in the very same effort.
So, I am going after the 20% that consume 80% of healthcare costs and engaging on an individual patient’s level in order to achieve maximum compliance the way they want to be engaged in order to keep them compliant and out of the hospital. This population is typically made up of indigent and elderly with one or more chronic conditions. (Shoot me now for being over simplistic and generalizing.) Each of those populations comes with their own ability / struggles to connect, engage and increase compliance. A Medicaid / Indigent patient may be hard to get a hold of and change phone numbers (using prepaid cell phones). They may also pawn the technology in order to financially survive. An elderly patient may not have or want access to state of the art technology. We need to accommodate for both of these scenarios.
The reality of the situation with the 20% that consume 80% (Indigent and Elderly) that a indigent patient may not have money to pay for their medication, but they will keep their cell phone and cable bill paid. This is where some say I cross the line and go into perverse incentives. Remember my goal is to keep people out of the hospital and engage on their terms. I believe in building loyalty and incentive programs into the connected monitoring programs in order to achieve maximum compliance. My critics would suggest that in this population, if the patient would be compliant in all their readings and call in regularly to stay connected that they would send them a gym membership. This is a double reward because it rewards for being compliant, but also helps maintain weight, glucose, blood pressure, etc., in order to keep a patient stabilized. I totally believe in this thinking, but not all people are going to utilize this incentive and it shouldn’t be the only incentive given.
In the case of my neighbor, she has extreme thrombosis and can hardly walk. She is not going to use the gym membership. One place to capture her attention is at the TV. If in between her shows the monitoring application pops up and asks her if she took her medication today or is it ok for the nurse caregiver to call you now and she does this religiously, then maybe, just maybe we give her a subscription to Netflix for being compliant. (Ok, I just heard the world explode, because this is a perverse incentive, but it keeps her compliant – engaging her at the level she wants.)
Years ago, when we started with a Smartphone app, we aligned with a major disease management company that gave $20 Walmart cards to the patients if they would just call in and stay connected. Critics once again pointed out that they would take the $20 card back to Walmart and buy candy, we should have given them certificates for fruit or healthy food. We also went as far as when we offered them a dedicated phone to take their readings and stay in contact with us – that if they were compliant that we would allow them to use the phone by crediting them minutes each month.
I know that this is a very touchy topic and we need to do whatever we can to do more with less, increase the quality of care, but at the same time reduce healthcare costs.
This is going to involve A LOT of out of the box thinking with a multitude of solutions that engage patients at their level, but in the end creates a positive result. Over the past month or so, I have used the phrase A LOT when dealing with my siblings and parents: “I don’t care if we lose the battle (meaning my parents can do it however they want, as long as they are engaged), as long as we win the war (accomplish the objective).” In the end, isn’t that truly the same in engaging patient in healthcare?
I would like to hear from you and this subject.
What are your thoughts about the 20/80 rule in healthcare?