Remember Million-Dollar Murray?
Murray Barr
Million-Dollar Murray is, in the parlance of health-policy experts, a “patient with complex needs,” or, in the words of front-line workers, a “frequent flier.”
We don’t pay nearly enough attention to these patients – a point that was well made in the report of the Commission on the Reform of Ontario’s Public Services
According to U.S. research published this year in the Journal of the American Medical Association, just 1 per cent of patients account for one-quarter of health-care costs, 5 per cent of patients gobble up half of the health-care budget, and the top 10 per cent of users are responsible for 64 per cent of health spending in any given year.
These numbers should come as no surprise. Health – like money – is not evenly distributed across society. At any given time, the vast majority of people are healthy, or at least not in need of medical care, while a tiny percentage are very ill.
Patients with complex needs come in many iterations.
There are patients who spend long periods in intensive-care units after traumatic spinal-cord injuries or who are ventilator-dependent whose one-time costs are astronomical.
And there are people like Mr. Barr with severe mental-health and addiction problems who cycle in and out of hospitals with an endless array of woes. They are costly to the health system in large part because we criminalize illnesses such as addiction and fail to provide adequate social supports for those with mental illnesses.
But the real “million-dollar babies,” according to the JAMA article, are those with multiple chronic conditions such as heart failure and diabetes. These patients – many of them frail seniors – take myriad drugs, can require costly interventions such as dialysis for long periods, and are shuttled routinely between various parts of the health system such as the emergency room, acute care, home care and institutional care.
When confronted with these data, the natural Canadian reflex is to say: “That’s the U.S.; it doesn’t apply here.”
Well, a 2010 study by the Canadian Health Services Research Group showed that 1 per cent of patients account for 49 per cent of hospital and home-care costs in Ontario, and 10 per cent account for 95 per cent of these costs in a given year. Similarly, the Institute for Clinical Evaluative Sciences found that 1 per cent of the population accounts for 34 per cent of all publicly funded health costs, and 10 per cent for 79 per cent of costs.
There are a few reasons these complex patients are so costly.
One is that we tend to overtreat, particularly at the end of life. Inefficiency of the medical system is also a major factor. The Organization for Economic Co-operation and Development estimates that one-third of health costs in Canada are “wasted.”
For example, one in every 20 patients in Canadian hospitals is alternative level of care, meaning that they no longer belong in hospital but there is nowhere to send them. This enormous expense is the direct result of a lack of investment in home-care and palliative care.
Similarly, about one-third of heart-failure patients who are admitted to hospital are readmitted within 10 days. Why? A lack of co-ordination and follow-up care, which results in post-surgical infections and a failure by patients to take their meds. When those patients are seen by a doctor within two days of discharge, their readmission rate falls by almost half. But our health system is siloed and treatment is rarely seamless.
