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The Globe and Mail

We need to treat 'million-dollar' patients better

Remember Million-Dollar Murray?

Murray Barr, a homeless alcoholic man in Reno, ran up the largest medical bill in Nevada, more than $1-million in the decade he lived on the streets, a story made (in)famous by Malcolm Gladwell in The New Yorker.

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."

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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 (the Drummond report).

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.

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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.

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Hospital care is intense and focused, but "there is a large voltage drop in intensity of care after discharge," notes Irfan Dhalla, a staff physician at St. Michael's Hospital in Toronto. He is heading a research project called The Virtual Ward. When complex patients are discharged from hospital, they are immediately placed in the care of a team that does follow-up in the community. Presumably, readmissions will fall sharply but the results are not in yet.

There is a similar approach at Vancouver Coastal Health, which has a program it calls Home ViVE (Visits to Vancouver's Elders), in which doctors and nurses make home visits to the frail elderly in a bid to break the vicious cycle of 911 calls, hospital admissions then return home to get sick again. Home visits cut the much-more-costly emergency-room visits by more than half.

Another example comes from the Pointe-de-l'Île Health and Social Services Centre in Montreal's east end. In its pilot project, patients with complex health needs are given equipment that allows telemonitoring of key measures such as blood pressure and blood glucose. One nurse monitors 80 patients. So far, the program has seen home visits drop to two from 12 a month for each patient and ER visits halved – all for a capital investment of $5,000, which is recouped in about three months.

These examples – presented at a recent conference of the Canadian Health Services Research Foundation – are but three among hundreds of innovations that exist around the country. The real question is: Why are they not ramped up? Why is the knowledge not shared?

As we discuss health reform, there is often an oppressive sense of gloom, that the job is so massive that we don't know where and how to start. But we do know. If you can provide better-quality, more-cost-effective care to the most frequent users of the system, then you go a long way toward controlling overall costs.

Every business knows that you have to focus on the needs of your most loyal customers, your frequent fliers. It is no different in health care: The Million-Dollar Murrays and their variations should not be reviled; rather, they should be studied, understood and treated more efficiently.

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