I’ve been fortunate to meet people in the healthcare industry from all over the world. From attending and speaking at conferences like TEDMed and Rock Health to meeting some of the finest industry veterans right here in Nashville, TN., I’ve learned that the healthcare industry attracts some very special people, many who want to make a real difference in the lives of others. I’ve also learned that many of us have a story behind why this industry called us to do what we do. So, here’s a little bit of mine….
In 2013, I founded Utilize Health, a neurological care management solution that helps patients with severe neurological conditions effectively navigate the healthcare system and recover to their fullest potential while saving costs for all stakeholders involved. It’s a solution that has yielded fantastic results and has been in the making for more than 14 years.
Fourteen years ago, I was a springboard diver, and if you’re going to be good at springboard diving, you must also train in gymnastics. One evening, I was practicing a front double tuck with a layout twist and I landed on my head. I heard a crunch, my body went numb, and I couldn’t move.
Doctors told me I had suffered a spinal cord injury and was paralyzed. This is where my struggle in today’s healthcare system began. After my surgery, I was transferred to an inpatient rehab center where I began relearning simple things like how to get dressed, how to get in and out of a bed, and how to “do” my life in a wheelchair. Doctors said I would never recover, but I wasn’t ok with that prognosis. My family and I traveled across the country searching for treatment options. It took countless hours of rehabilitation, visiting facilities in 12 different states, and nearly 6 years, but today, I’ve accomplished what was considered impossible. I walk, and I walk completely unassisted and with limited to no feeling below my chest.
What’s interesting about many neurological injuries or diagnosis is that one is never completely recovered or healed from that core neuro diagnosis. Recovery is a lifelong process; it’s not episodic. Even today, 14 years later, I still notice functional improvements.
So what did this experience teach me about healthcare? Complex or “specialty” conditions like neuro are high cost, complicated, low outcome problems for health plans in America. Here’s why:
- Neurological conditions are incredibly complex and don’t play well by the rules! Patients with neurological conditions are among healthcare’s most complex and challenging patient populations to treat, both from a diagnostic and treatment perspective. Most other healthcare conditions or procedures have “normal” and “expected” outcomes within “normal” and “expected” timeframes, such as a hip replacement or cardiac bypass procedure. The patient goes in for a procedure and remains in the hospital for a usual and expected amount of time. At discharge, orders are written with new medications prescribed or adjusted and expected postoperative activities defined. Thereafter, the patient begins rehab, again for a typical or usual period of time. That patient is usually back to “normal” or is even better than he or she was prior to the procedure–with predictable outcomes that are achieved within a “normal” and “customary” time frame.Conversely, neurological conditions do not follow the same “expected” course. As with other specialty patient populations, outcomes are incredibly varied and do not follow an expected path or timeline. Consider a spinal cord injury patient like myself. There are a number of secondary conditions that occur with the complexity of an injury like this that can escalate into life threatening conditions rather quickly. For a spinal cord injury patient, a simple urinary tract infection can quickly become life threatening. A pressure ulcer is always serious, but for those with a spinal cord injury, pressure ulcers are not felt, so early signs are missed, allowing the missed condition to escalate into a serious and sometimes life threatening condition.
- Patients with neurological conditions are difficult for health plans to uncover in their data, and therefore, they often go unmanaged and their costs increase. The complexity of neurological conditions comes with an equal difficulty in tracking them in claims data. The length of care and recovery for neurological conditions creates a long medical history where the initial diagnosis is often forgotten unless the patient himself brings it to the forefront of a provider’s attention. The initial diagnosis for a neurological condition is stabilized in the acute care setting, but the further out from the initial diagnosis, the further the patient’s neuro diagnosis falls off the radar within claims data. Those secondary conditions are seen, but not the initial neurological diagnosis which causes common secondary conditions to be life threatening. For instance, if I get a common cold, I have to seek medical attention quickly, or I escalate into pneumonia in a very short time largely because I can’t mobilize my own secretions. When I present to a provider with a cold, I am usually diagnosed with upper respiratory infection. That’s the medical claim submitted, not that I am a spinal cord injury patient with an upper respiratory infection. While being easier to file for billing purposes, it detracts from good continuity of care. It’s imperative that the provider understands the context of a secondary condition in light of my spinal cord injury.Quite often health plan members with neurological conditions are misclassified. They are misclassified because they’re classified according to the original diagnosis category. An example is seen with stroke patients. Stroke patients are initially categorized as cardiovascular, even though they have the highest chance of recovery if you treat them through a neurological lens. Yes, the initial event IS cardiovascular, but the residual conditions that will be with the patient for the rest of his or her life, are neurological, e.g. paralysis, inability to speak, to walk, etc. As such, it makes sense for the coding system to integrate innovative ways to connect conditions and after effects to improve the manner in which we care for patients.Sifting these patients out as a discernible category and making sure they are treated as a neurological patient can save millions for health plans and improve patient outcomes drastically.
- Neurological conditions cost the healthcare system a lot of money
The sheer complexity and length of care/recovery for neurological conditions alone makes this a costly population. Patients with neurological conditions have higher hospital readmission rates and higher average length of hospital stays compared to average, more predictable patients. Eleven of twenty patients with neurological conditions are readmitted annually with an average length of stay of 24 days. Compare that with the rest of the total patient population who has a 1 in 20 chance of being readmitted with a 2-3 day average length of stay. Add in the unpredictable secondary conditions and the price grows even more. The lack of adequate post-acute standards of care drives the total cost of this population up much further than it needs to be. This population, only around 4.5% of the entire population, accounts for up to 12-24% of total healthcare costs!
How do we solve this problem?
Here’s where specialty care management programs with focused clinical staffs can offer resolution to this increasingly neglected population. For patients with neurological conditions, focused programs are better for understanding each individual patient, the uniqueness of that patient’s needs, as well as how the neurological condition manifests. With such focused neuro expertise, a specialty care management team can get that patient to the appropriate level of care faster than a case manager with a broad caseload of patients having different types of conditions.
Though there is no single post-acute standard of care, we’ve found a methodology to produce the best evidence-based practices that identify patients with neurological conditions, pull them out of claims data, and get them the best possible treatment and/or treatment settings based on their respective neurological conditions and secondary conditions. We have made neurological focus possible by creating a specialty neurological care management program that focuses on this complex, underserved patient population.
Of course, neurological conditions aren’t the only area that can benefit from this approach. The generalist is making way for the specialist, and that’s a good thing for patients and health plans alike.