Dr. Charlie Miraglia is the Chief Medical Officer at hc1.com. Connect with him on Twitter @ccmiraglia!

It was around this time of year (August 5th to be exact) 32 years ago that Joel, played by a young Tom Cruise, sped through town in his father’s Porsche while his parents are out of town, heading unknowingly toward a financial disaster. After the Porsche ends up in Lake Michigan, he finds himself needing to make a lot of money in a short period of time. So begins the classic film Risky Business - and that’s when things start to get interesting.

In our current healthcare transformation, we also seem to be speeding toward something (hopefully not disaster) and, not unlike Joel, we also need to find some creative ways to finance our activities. One of the leading strategies to accomplish this is referred to as “value-based” payments, and it’s been estimated that 75% of healthcare businesses will operate under this shared-risk model by the year 2020. To accomplish this, the risk associated with the care of large populations of patients will need to be spread around a bit, to hospitals, providers, long term care facilities, skilled nursing homes, and more.

Logic dictates that step one would be to understand where the majority of costs in the system currently exist. As it turns out, the highest healthcare costs are concentrated on a very small subpopulation of patients. In fact, almost half of this country’s total personal health care dollars are spent on the top 5% of patients. It seems obvious, knowing where the money is spent, that the next step should be to identify the patients who are in this category and engage them in ways that can over time decrease dollars spent through earlier medical interventions and wellness campaigns.

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Improved care coordination is at the heart of any potential solution to our healthcare problems. If better outcomes and lower costs are the primary goals of this new “patient-centric” approach to healthcare, best practices for identifying patients at risk and improving their transitions of care throughout the healthcare journey will be of paramount importance.

It should not be a surprise that the patients in this category of high resource utilization would be the ones who are near the end of their lives, have multiple chronic disorders, or undergo high cost events such as organ transplants. These are the patients who have the most need to be managed proactively. They are the most medically complex and therefore the most likely to need readmission to the hospital for another event. Armed with this knowledge thanks to up-to-date clinical data and real-time intelligence related to their condition and trending diagnostic information, providers can more accurately stratify, and hopefully mitigate, these risks.

In the past, physicians relied heavily upon what patients told them about their health and the pearls of wisdom they could extract from a stack of papers full of laboratory and radiology diagnostic information. Time delays were common, so looking in the rear view mirror was an unfortunate way of life. With data more accessible these days, populations can be identified for intervention more readily, so they can be placed in treatment programs as outpatients before the need for hospitalization occurs.

If the high costs associated with healthcare are going to be reduced, delivering greater value to healthcare consumers and engaging patients and providers will need to be adopted. One thing is certain, however - change is always difficult. So this transformation of healthcare, for the foreseeable future at least, will remain a “risky business”.

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