Return on Investment for Optimal Medical Therapy
The benefits of optimal medical therapy (OMT) on clinical and financial outcomes in patients with cardiometabolic disease are firmly established in the material covered on this site. I have two decades of experience in delivering OMT and achieving the clinical goals. I am completely convinced we can produce better financial outcomes today than those cited in the literature by consistently producing the OMT product.
Five percent of patients generate 50% of the costs. Many of these are patients with multiple chronic conditions and in the Medicare population would include those with heart attack, chronic kidney disease, heart failure, hypertension, diabetes, and hyperlipidemia. They don’t just have heart disease. They have multiple conditions. The biology causing these conditions is all related and it impacts every organ and cell in the body. OMT interferes with that biology to protect all cells and organs, not just the heart. Disease management programs operating in parallel with primary care do not reduce costs. Here is the solution that works:
“KP (Kaiser Permanente) developed a new model for treating people with multiple but relatively manageable chronic diseases—focusing on both those who are currently in the top 5% and those who could end up there in the coming years if their medical problems worsen and their health deteriorates. We believe that addressing this entire group of patients presents the biggest opportunity for improving outcomes and increasing savings. Our approach uses technology and relatively inexpensive medical staff to provide expanded support to primary-care doctors so that they can oversee and address the chronic needs of patients directly instead of relying on largely independent disease-management programs.”
The best information for ROI from this approach comes from a controlled trial at Kaiser Permanente involving patients with a heart attack or unstable angina. The trial was done in their cardiac rehab program. The estimated cost was a dollar a day. The savings amounted to $60 a day. They saved $21,900 per patient per year ten years ago. Today that would be about $30,000 per patient per year. They started small, with a thousand patients, but at last report they had 12,000 patients in the program. That should generate savings of $280,000,000 in one state by a focus on just 12,000 people. If you identified these patients when they had type 2 diabetes with chronic kidney disease, most of them would not have a heart attack over the next 13 years preventing their entry into the five percent of most expensive patients.
Let’s say your organization cares for 100,000 Medicare patients. 12.6% or 12,600 should have a history of heart attack. That is 12,600 heart attacks in your population times $21,900 in savings per patient per year equals $275,940,000 in savings compared with usual care. One would predict nearly as many additional patients with heart artery disease (11,600) and their risk/potential cost savings is almost as high. That almost doubles the impact.
Patients who end up with acute coronary syndrome all have a cardiometabolic condition that is not just impacting the heart, it is impacting every organ and cell in the body. OMT is very specific. Teams of primary care physicians and nurse practitioners using protocols focus on treating high blood pressure, hyperlipidemia, diabetes, along with smoking cessation and aspirin for very high-risk individual. It is the team and the focus that makes the difference. These teams at Kaiser increased the number of patients on a statin from about half to 91% and hypertension control to 90%.
We need not change any of your current programs and we can do this at minimal cost. We can begin with a small pilot with a single primary care doctor and a nurse practitioner already on your staff who are early adopters and interested in chronic cardiometabolic disease management. They would be the first providers in an advanced medical home for cardiometabolic disease. I supervised a team like this that managed patients with high-risk diabetes and hypertension in a large medical group for a Fortune 100 company. We dramatically moved the needle.
Pharmacists in the Kaiser program had 800 patients in their panel. I think a nurse practitioner can handle 500 because they will be the primary care provider for those patients, and they will have other needs. The team can treat new patients and others in the organization who are not at goal. The physician also has a smaller panel than a usual PCP. She is there to address protocol exceptions and complications. The program can be quickly expanded. We should quickly have enough data to compare with usual care in your institution. You already have the staff and facilities. You have population health tools. We can do this work with very modest addition cost and very strong ROI.
If we started with a physician and 3 nurse practitioners in the advanced medical home team, and they managed an average of 500 heart attack victims each, for a total of 2000 patients, that would result in a 76% reduction in mortality and $44 million in annual savings compared with usual care. Even if it is half of that, a tenth of that, it would be an excellent result. I am confident we could do that with a dollar a day in added cost per patient.
Maybe we don’t produce a 60 to one ROI, but I am confident if we attack high-risk cardiometabolic disease with a team addressing high-risk, high-cost patients, you will be very happy with the result.
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