MedicalResearch.com Interview with:
Donna Zulman MD MS
Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park
Division of General Medical Disciplines, Stanford University, Stanford California, USA
Medical Research: What is the background for this study?
Dr. Zulman: Within the United States, a small number of individuals account for disproporationate health care spending. Many of these high-cost patients have complex chronic conditions such as heart failure and diabetes. Others have complicated mental health conditions. But the vast majority have multiple chronic conditions, which can create challenges when patients are navigating their health care. For this study, we examined patterns of chronic conditions among high-cost patients in the Veterans Affairs (VA) Health Care System, and studied the relationship between different chronic conditions patterns and health care utilization and costs.
Medical Research: What are the main findings?
Dr. Zulman: We found that within the VA, the 5% highest cost patients accounted for 47% of total VA health care costs. Approximately two-thirds of these patients had chronic conditions affecting 3 or more body systems (for example, cardiovascular disease, asthma, and depression). However, patients with severe, dominating diseases such as cancer and schizophrenia were less likely to have a lot of comorbid conditions.
In addition, we found that even among these high-cost patients, having more conditions was associated with greater use of outpatient and inpatient services. However, as patients’ multimorbidity across body systems increased, a greater share of their costs was generated in the outpatient setting and a smaller share of their costs was generated in the inpatient setting. This suggests that interventions focusing on high-cost patients should not only target costly hospitalizations, but should also coordinate and maximize efficiency of outpatient services across multiple conditions.
Medical Research: What should clinicians and patients take away from your report?
Dr. Zulman: There is growing interest in health care delivery models that focus on high-risk and high-cost patients. Our study illustrates the heterogeneity of these patients’ needs. Many of these patients have multiple chronic conditions and will require intensive care coordination. Others may have a single dominating condition and may benefit from a focused program such as the interventions offered through comprehensive cancer and mental health clinics. Many patients have conditions such as depression and anxiety that need to be addressed together with their other medical conditions. Most importantly, programs focusing on high-risk and high-cost patients need to ensure that their interventions extend beyond preventing hospitalization and should identify opportunities to reduce the volume and burden of outpatient care for patients with multiple chronic conditions.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Zulman: We still have a lot to learn about health trajectories among these high-risk patients. Ideally, we’d like to identify patients before they develop complex multimorbidity profiles, and provide preventive services early on. An important challenge for future research is to understand how social determinants of health and other risk factors interact with clinical needs and influence health care utilization patterns over time. There is also a lot of work to be done to identify the most effective and sustainable interventions for these vulnerable patients.