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What about your five percent?

Five percent of people account for half of all medical costs.
That’s true for group health, Medicare, Medicaid, workers comp – pretty much every line of coverage.
You know that, I know that, we all know that.
But what do we DO about that?
Why do most payers use the same generic approach across all members, geographic regions, provider types, disease conditions, employers, when we all know health care is local, people are very different, surgical cases are quite different from medical ones, and non-specific back pain is NOT the same as a spinal injury.
Not surprisingly, there’s a strong correlation between obesity (and related conditions) and high cost claims. And half of the patients in the top five percent had hypertension, one-third had high cholesterol, and more than one-quarter had diabetes.
Here’s one idea. Identify patients with hypertension, hyperlipidemia, obesity (use BMI) and/or diabetes, and triage them to a clinical resource (nurse) trained in, and equipped to, address their issues. Whether you’re in the workers comp, group, or Medicare/Medicaid world, the impact of these unhealthy folks on your results will be mitigated if you pay attention right up front rather than discovering some months down the road that the ‘simple bad back’ has become a very expensive, long term, chronic pain case.

One thought on “What about your five percent?”

  1. Joe –
    There are many millions of patients with hypertension, hyperlipidemia or obesity whose condition is well managed by inexpensive generic drugs.
    In any given year, I think you will find many of the high cost cases in the following categories: (1) people in nursing homes, (2) patients with congestive heart failure (CHF), (3) patients with severe mental illness, often coupled with alcohol and drug abuse, and (4) patients undergoing cancer treatment.
    Patients in the first three categories probably account for a disproportionate number of hospital “frequent flyers.” More could be done, I think, to better manage nursing home patients if primary care docs were paid enough to see them and treat them in the nursing home, though nursing homes are also quick to send patients to the hospital after a fall even if they are uninjured. Nurse outreach and other disease management techniques could probably help to reduce inpatient bed days among CHF patients. Patients with mental illness are tougher to deal with. There may not be as much that can be done with medical management here other than to find ways to improve compliance with taking medication. For cancer patients, the issue is cost vs. benefits of new treatments, access to palliative care and ensuring that patients fully understand their prognosis and their treatment options including costs and possible side effects.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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