HCI3 Update from the Field: The DNA of Medical Episodes

Submitted by francois.debrantes@hci3.org on Friday, April 4, 2014 - 04:56

We call it the DNA of medical episodes because it tells you a lot about patients and the way they were managed (or mismanaged) – There are lots of different ways to look at how health care resources are being used. In a recent podcast, Bruce Landon, Scott Halpern and Carrie Colla discuss the importance of clamping down on the "grey zone" of medicine, where provider discretion can make a big difference. For many years we've been looking at the sequelae of sub-optimized care, namely potentially avoidable complications. Both of these approaches attempt to answer a simple question: Was the care given appropriate? If you clamp down on the grey zone, then you reduce provider-sensitive care, but the consequence might be the emergence of additional avoidable complications. So the two seem necessary to really view the provision of care from the patient's eyes. Of course there's another way to look at health care resources, the throwback to the days of utilization management, where you don't worry about appropriateness at the patient level, but rather focus on the specific resources used by any provider for any slice of the care they delivered. That view is clearly anachronistic and, quite frankly, both useless and destructive. And yet it survives to this day in Medicare in the form of "resource use reports".

What this means to you – We know we have a long way to go to move from the silo mentality of health care that is encouraged by the fee-for-service payment system, and Medicare, Medicaid and private payers are all playing their part. This new e-book from Bruce Japsen illustrates how the ACA is accelerating that trend, but the institutional resistance of the middle bureaucracy to change is still strong. So today we offer this view of patient claims in the hopes that it will open the eyes of those who still cling to the antiquated notion that resource measurement should be provider centric, and not patient centric.

Here are 5 patients who all had a number of medical episodes during the year. Each vertical mark represents an encounter – the smaller ones are outpatient visits while the thicker ones are inpatient. The blue ones represent typical care while the red represents avoidable complications.

Because certain treatments are related to certain conditions, the overlap between the two episodes is total and one gets included in the other. If one were to examine each intervention separately, you wouldn't learn much about the way a patient is being managed, but looking at this longitudinal view – from the patient's experience – pretty much tells you what you need to know. Like DNA strands, they reveal much. Member 5 had a PCI followed by an AMI (that's an avoidable complication). The AMI was treated with a complex CABG during which there were further complications, and in the midst of the complex CABG episode a Gall Bladder surgery. Only clinical records can tell you what was truly appropriate, but this picture certainly causes us to ask some questions. And that's what's really important. At some level, who cares whether one or more lab test or X-ray was done. When there's this amount of red, something's not right, and that's where payers and providers should focus their attention.