A stronger doctor-patient relationship for the costliest patients

Patients who are frequently hospitalized account for a disproportionate amount of health care spending in the United States. Working with a $6.1 million grant, a new University of Chicago Medicine program will test whether an updated version of the traditional general practitioner can reduce spending while also improving care for these patients.

Under the new model, funded by a from the Center for Medicare & Medicaid Innovation, multidisciplinary teams led by a comprehensive care physician (CCP) will care for patients in both outpatient and inpatient settings. By improving the continuity of an individual's care after a hospital stay and strengthening the bond between doctor and patient, the model hopes to provide better care at lower cost.

"Our goal will be to really understand patients' needs so that we can give them the care that they need," said lead investigator David Meltzer, MD, PhD, associate professor and chief of the Section of Hospital Medicine at the University of Chicago Medicine. "That should be better for them, and should ultimately be less costly for the health care system and produce better outcomes."

The model is built upon 15 years of research by Meltzer and colleagues on the changing medical work force in the United States. Health care providers increasingly rely on specialized physicians known as hospitalists to care for inpatients, while primary care doctors are less likely to see their patients while they are hospitalized. Though Meltzer found that this rearrangement has produced modest benefits in terms of health outcomes and reduced spending, it also has created unintended rifts in a patient's care.

"A whole series of trends have emerged over time that has made the traditional continuity in the doctor-patient relationship between the outpatient and inpatient setting more difficult," Meltzer said. "It's not that doctors don't understand this continuity is important or don't want to provide it; they face real barriers in caring for patients in both the inpatient setting and the outpatient setting. By focusing on frequently hospitalized patients, our CCPs will be able to have a real presence in the hospital and clinic on an almost daily basis."

Previous research supports that a strong doctor-patient relationship can lower the nation's health care tab. A 1984 Veterans Administration study compared patients who saw the same primary care doctor at every clinic visit against patients who saw a different physician each visit. It found reduced hospitalizations, hospital stays, and intensive care unit (ICU) usage in the group with higher continuity of care. Another study found that advanced lung cancer patients with integrated outpatient and inpatient care were 25 percent less likely to enter the ICU before death.

"There's a huge literature suggesting that elements of the doctor-patient relationship, including trust, interpersonal relations, communication, and knowledge of the patient, are all associated with lower costs and better outcomes," Meltzer said.

While the "Marcus Welby" style of doctor who manages all facets of care in and out of the hospital is no longer economically feasible – or necessary – for all individuals, Meltzer proposes that comprehensive care could be useful for patients at the highest risk of repeated hospitalization. Such patients, dubbed "hot spotters" by surgeon/writer Atul Gawande, account for a significant portion of in the United States, with one estimate concluding that 5 percent of Medicare beneficiaries account for 40 percent of spending.

In Meltzer's model, a comprehensive care physician will lead a team of nurse practitioners, social workers, care coordinators and other specialists best suited to address the needs of such high-risk patients. CCPs will carry a panel of approximately 200 patients at a time, serving as their primary care physician during clinic visits and supervising their care while hospitalized.

The trial will enroll patients from the South Side of Chicago who are predicted to spend an average of 10 days a year in the hospital. Many of these patients are expected to be general medicine patients with chronic diseases, geriatric patients living in residence homes or patients with renal disease receiving regular dialysis treatment. Five CCPs will be recruited to serve as team leaders for the demonstration project, which is expected to begin in fall 2012. A total of 11 new jobs will be created by the project.

"One of the highest priorities in our efforts to lower health care costs is to reduce the rate of expensive hospitalizations," said Kenneth S. Polonsky, MD, dean of the Biological Sciences Division and the Pritzker School of Medicine and executive vice president of medical affairs at the University of Chicago Medicine. "Dr. Meltzer's innovative approach to this problem offers real hope that we will be able to deliver more health care in the community even to the sickest patients."

The Health Care Innovation Award for the comprehensive care program is one of two received by the University of Chicago Medicine – the only academic medical center in Illinois to receive multiple awards from the $900 million initiative. Previously, a $5.9 million grant was awarded to the institution in May to create the CommunityRx system, which will connect with community resources and services.

"For our institution to have two of these grants awarded is a real testimony to the forward thinking and innovative ideas that are here on our campus to deal with some of these very vexing public health and coordination issues," said Sharon O'Keefe, president of the University of Chicago Medical Center.

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