High Cost Patients

Jessica Borne, Alysia Cummings, and Carolyn WadsworthHigh Cost Patients

Background

(National Institute for Health Care Management [NIHCM], 2012)

Background, contd

(NIHCM, 2012)

Background, contdHistory of high cost patientsSpending has become slightly less concentrated in the top 1%Accounted for 28% of healthcare spending in 1987 and 22% of spending in 2009Contributed to the rise in obesity rates and secondary illnessesA greater share of the population now requires moderately high medical expenditures(NIHCM, 2012; Stanton, 2006)

Background, contdCharacteristics of high cost patientsTypically older and in poor healthLikely to rate their health as fair or poorRisk of being a high cost patient directly related to the number of functional limitations and chronic conditionsIMS Institute for Healthcare Informatics77% have at least one chronic disease16% have battled cancer at least once13% diagnosed with specialty condition or autoimmune diseaseHigh cost patients often receive poorly coordinated care(IMS Institute for Healthcare Informatics, 2012; NIHCM, 2012; Powers, Chaguturu, & Ferris, 2015)

Impact on Occupational Therapy (OT) PracticeHigh cost patients and healthcare reformEmphasis on health promotion and prevention with passage of the Patient Protection and Affordable Care Act of 2010 (ACA)High-risk care management programsAimed to increase quality of care and decrease overall costsTypically run by payers or third-party vendors in the pastGrowing trend for these programs to now be based in medical practices(Anderko et al., 2012; Hong, Siegel, & Ferris, 2014; Powers et al., 2015)

Impact on OT Practice, contdThe ACA and Accountable Care Organizations (ACO)ACOs are integrated networks of providers working togetherImprove individual and population level health outcomesCoordinate careShare accountability for the quality, cost, and outcomes of patientsAddress rapidly rising healthcare costs and related inefficienciesReimbursement is benchmark-based related to outcomesSavings achieved through prevention, improved self-management, reduced hospitalization, reduced length of stay, and/or successful discharge planning(AOTA, 2012)

Impact on OT Practice, contdThe ACA and Patient-Centered Medical Homes (PCMH)A priority of the ACA is to develop innovative models of health care delivery systemsReduce fragmentation of careImprove efficiency and outcomesReduce health care costsPMCH is a primary care modelPatient-centered, coordinated, team-driven careEach patient is assigned to a physician-directed practice and personal physicianHeld accountable for providing and coordinating entire spectrum of care(AOTA, 2012)

Impact on OT Practice, contdACOs, PCMHs, and OTACO and PCMH principles align with traditional occupational therapyOccupational therapists are trained to improve quality of life, function, and participationOccupational therapists provide team-based, coordinated care that is patient-centered, family-focused, and holisticClearly articulate OT program of care, the cost of that care, OTs role on the team, and the expected outcomes of careCoordinated care across settings is an important aspect of OT involvement

(AOTA, 2012)

The Role of OTChronic Disease ManagementHealth Promotion & PreventionPrimary Health Care

The Role of OT: Chronic Disease ManagementEvaluation and treatment of occupational deficitsEducation of patients and familyModification of activitiesEnergy conservationHealth managementImprove quality of lifeMaintain independence through self-managementProvide community resources and supports(AOTA, 2015; Hand, Law, & McColl, 2011)

The Role of OT: Health Promotion & PreventionExamples of preventative strategies currently in practice:Falls prevention programs, parenting skills training, promotion of healthy habits, injury prevention in the workplace, support groups, social, leisure, and life skills participation groups, ergonomic assessments, backpack awareness, and caregiver educationWellness and health promotion groupsIs prevention an appropriate role for an occupational therapist in the acute setting?Can help prevent hospital readmissions(AOTA, 2013; Matuska, Giles-Heinz, Flinn, Neighbor, Bass-Haugen, 2003; Roberts & Robinson, 2014)

The Role of OT: Primary Health CareAOTA Position Paper: Role of OT in Primary CareAOTA asserts that occupational therapy practitioners are well prepared to contribute to interprofessional care teams addressing the primary care needs of individuals across the lifespan, particularly those with, or at risk for, one or more chronic condition (2014, p. S25)Who Better?Because occupational therapy professionals are broadly trained in human development (cognitive, physical, social, emotional), health promotion, disease process intervention, activity analysis and behavior modification, lifestyle interventions, and use of adaptive equipment, the profession could be fundamental to reducing fragmentation in health care (Muir, 2012, p. 507)

The Role of OT: Primary Health Care, contdWhat do we need to do to promote OTs role in primary health care?Get familiar with the setting and terminologyStrengthen relationships with primary care providersAdvocate to be considered a team member in primary careExamine OT literature and promote the role of OT in primary care(Metzler, Hartmann, & Lowenthal, 2012)

ConclusionHigh cost patients account for a disproportionate share of health care costsChronic conditions and functional limitations increase a patients riskHealthcare reform emphasizes heath promotion and preventive careHealthcare reform principles align with OTOccupational therapists are well suited to manage patients with chronic care conditionsAOTA is advocating for OT as a primary care provider

ReferencesAmerican Occupational Therapy Association. (2012). Accountable care organizations and medical homes. Retrieved from https://www.aota.org/-/media/Corporate/Files/Advocacy/Health-Care-Reform/ACO/ACOs%20%20Medical%20Homes%20Fact%20Sheet%202012%20combined%20%20rev%2022012.pdfAmerican Occupational Therapy Association. (2013). Occupational therapy in the promotion of health and well-being. American Journal of Occupational Therapy, 67(6 supplement), S47-S59American Occupational Therapy Association. (2014). The role of occupational therapy in primary care. American Journal of Occupational Therapy, 68(Supplement 3), S25-S33.American Occupational Therapy Association. (2015). The role of occupational therapy in chronic disease management. Retrieved from https://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/HW/Facts/FactSheet_ChronicDiseaseManagement.pdfAnderko, L., Roffenbender, J. S., Goetzel, R. Z., Howard, J., Millard, F., Wildenhaus, K., & ... Novelli, W. (2012). Promoting prevention through the Affordable Care Act: Workplace wellness. Preventing Chronic Disease, 9(E175). doi:10.5888/pcd9.120092ReferencesHand, C., Law, M., & McColl, M. A. (2011). Occupational therapy intervention for chronic diseases: A scoping review. American Journal of Occupational Therapy, 65(4), 428-436.Hong, C., Siegel, A., & Ferris, T. (2014). Caring for high-need high-cost patients: What makes for a successful care management program? Retrieved from http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdfIMS Institute for Healthcare Informatics. (2012). Essential health benefit packages explained: Understanding high-cost patients. Retrieved from http://www.imshealth.com/deployedfiles/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/Healthcare%20Spending/IHII_Spending_Report.pdfMatuska, K., Giles-Heinz, A., Flinn, N., Neighbor, M., & Bass-Haugen, J. (2003). Outcomes of a pilot occupational therapy wellness program for older adults. American Journal of Occupational Therapy, 57(2), 220-224.Metzler, C. A., Hartmann, K. D., Lowenthal, L. A. (2012). Defining primary care: Envisioning the roles of occupational therapy. American Journal of Occupational Therapy, 66(3), 266-270.ReferencesMuir, S. (2012). Occupational therapy in primary health care: We should be there. American Journal of Occupational Therapy, 66(5), 506-510.National Institute for Health Care Management. (2012). The concentration of health care spending: NIHCM foundation data brief. Retrieved from http://www.nihcm.org/pdf/DataBrief3%20Final.pdfPowers, B. W., Chaguturu, S. K., & Ferris, T. G. (2015). Optimizing high-risk care management. Journal of American Medical Association, 313(8), 795-796. doi:10.1001/jama.2014.18171Roberts, P. S., & Robinson, M. R. (2014). Occupational therapys role in preventing acute readmissions. American Journal of Occupational Therapy, 68(3), 254-259.Stanton, M. (2006). The high concentration of U.S. health care expenditures. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/expendria.pdf