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Source: 
Albuquerque Business First

Dennis Domrzalski, Reporter- Albuquerque Business First

Never have so few accounted for so much spending.

According to a recent U.S. Department of Health and Human Services report, the top 1 percent of health care users in the U.S. accounted for 21.4 percent of the $1.3 trillion Americans spent on health care in 2010.

Many of those top users have multiple chronic conditions and they lack family and other social support networks that could help keep their conditions under control and them out of emergency rooms and hospitals.

In the past few years, insurers and health care providers have been focusing on keeping patients with chronic conditions out of hospitals and controlling their conditions in an effort to bring down costs.

I asked some of New Mexico’s health insurers what they’re doing to address the problem. All said they’re working on coordinated care models that try to control chronic conditions.

Stephen Forney, vice president and CFO, of Lovelace Health System, said many of those high users, or frequent flyers, as they are called, are, “predominately in nursing homes and in the latter stages of their lives. They have multiple conditions and their pharmaceutical costs are high.”

The first step in to get those chronic conditions under control is to identify them so that preventive care can be offered, Forney said. “At Lovelace Health Plan, we try to identify the individuals who fall into the higher risk categories and make sure they are getting the preventive and acute care they need and try to coordinate that care across all areas.”

Dr. Eugene Sun, vice president and chief medical officer at Blue Cross and Blue Shield of New Mexico, said that while there are no magical solutions to the problem, one way to control costs for frequent flyers is to go back to the way health care was practiced 30 or 40 years ago when family doctors knew their patients well and coordinated their care.

The model that is coming into use is called coordinate care, or patient-centered medical homes where primary care doctors lead teams of nurses, nutritionists, specialists, behavioral health practitioners and others to coordinate a patient’s care. “We have gotten fragmented in the past three or four decades. A patient can see a specialist and the primary care physician might never know about it,” Sun said. BCBSNM is working with ABQ Health partners to provide patient-centered medical homes for health plan members.

“We’re getting back to the basics of having a primary care doctor lead teams that include specialists, social workers and others to come up with a coordinated plan of care,” Sun said. “That includes information systems so that if a lab test is done or if a hospitalization occurs, all of that team can tap into that information electronically [through an electronic medical record], with the goal of improving outcomes and quality and doing it at a lower cost.”

Lisa Lujan, president of Presbyterian Health Plan, said that .5 percent of the health plan’s members account for 20 percent of its medical spending. It means that 2,500 members account for more than $200 million in annual medical costs, Lujan said.

PHP has a program in place for high-risk patients were a nurse and social worker meet with patients while they are in the hospital and before they are discharged to coordinate their post-discharge needs.

By the numbers

  • $1.3 trillion - Total U.S. health care spending in 2010
  • 21.4% - Spent on top 1% of users
  • 97.2% - Spent on top 50% of users
  • 2.8% - Spent on bottom 50% of users
  • Source: U.S. Department of Health and Human Services

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