Cutting health care's Gordian Knot

PHOTO: Cutting health care's Gordian Knot

Around the world, and in Singapore, systems that individuals rely upon for care - from hospitals to social services - are careening towards a critical breaking point. But to say that health and social care expenditures are getting too high is hardly providing an insight.

Healthcare spending includes a significant amount devoted to the treatment of preventable or at least manageable conditions. And research repeatedly shows that a vast majority of healthcare costs are associated with a small minority of the least healthy, high-cost, high-need patients.

According to the World Health Organisation, chronic illnesses - including heart disease, lung diseases, cancer, and diabetes that have been linked to lifestyle risk factors - have reached global epidemic proportions. They now cause nearly two thirds of all deaths worldwide, more than all other diseases combined, and consume an increasing proportion of healthcare costs.

Care systems around the world vary widely, but wherever they are, health and social care providers and policymakers are confronted by a single daunting challenge. As more people live longer, grey faster and suffer from chronic illnesses, governments including Singapore's are under enormous pressure to curtail spiralling healthcare spending while at the same time deliver better outcomes and quality of care.

The two seemingly contradictory goals are achievable only with greater efficiency and stakeholder collaboration, so that health and social care providers can deliver care that is integrated as well as people-centred.

A 360-degree view

There is no lack of data to brainstorm ideas. However, any integrated-cum-individualised care programme requires a 360-degree view of the patient. Does her living environment make her vulnerable to certain illnesses? Does she have a social community or is she isolated? Does she have access to adequate nutrition?

All these interlinked factors influence her well-being and optimal care path. People with multiple health and social needs are also usually the biggest consumers of care services, which in turn drive up healthcare expenditure. This makes it critical to look beyond traditional health parameters, and factor in social determinants such as housing, education and income, to find innovative, informed ways to improve the health of individuals and families.

The pattern of providing treatment to patients and then sending them back into the same conditions that made them sick in the first place is obviously ineffective.

The delivery of care has to get smarter - with greater coordination, integration and sharing of information. In the case of Singapore, besides the Agency of Integrated Care which was created in 2009 to enhance collaboration in the community to create a well-connected healthcare system, the Healthcare 2020 Masterplan announced last year reflects the push for a paradigm shift in the way the country delivers care.

Other health and social care organisations globally are similarly transforming care delivery. In New Jersey, US, the Camden Coalition of Healthcare Providers is an example of coordinated health and social care that has shown promising preliminary results. Founded by Jeffrey Brenner, the coalition uses big data to pinpoint "hot spots" - places where a high density of people have complex medical, social and behavioural needs.

By analysing claims data from all three Camden health systems (Cooper University Hospital, Our Lady of Lourdes Medical Center and Virtua Health), Dr Brenner discovered that 80 per cent of the costs were spent on only 13 per cent of the patients, and 90 per cent of the costs were spent on 20 per cent.

These initial 36 "super-utilisers" - patients with various combinations of health problems including asthma, cancer, diabetes, drug addiction, heart disease, and obesity - averaged 62 hospital and emergency room visits per month.

After joining the collaborative care programme, their hospital visits were reduced by 40 per cent, cutting their hospital bills, which previously averaged US$1.2 million (S$1.5 million) per month, by 56 per cent to just over US$500,000 monthly.

Over in Catalonia, Spain, where 60 per cent of Catalonia's population aged over 65 has chronic diseases and consumes 70 per cent of the region's healthcare resources, the Catalan Institute of Health and the Catalonian government embarked on a pilot programme for more coordinated care around chronic disease management.

For more than 150 patients with complex health conditions, the pilot made it easier to see a single, shared, holistic view of each patient pulled from large volumes of Big Data located in several different sources. Multiple care providers - from doctors to social workers - could perform holistic and systematic assessments of patients, and determine their level of needs across different factors, such as daily living, nutritional and social care needs.

And caregivers could create and manage individualised care plans based on those patient assessment results.

Information silos

A key premise of integrated care is that health and social systems are interdependent. However, more often than not, information silos are formed, creating disparate approaches to delivering care. Every stakeholder in the system views the concept of care and well-being through their own vantage point.

Hospitals want to cure patients' diseases, community programmes want to encourage healthier lifestyle changes to reduce risk of illness, and charities want to assist those burdened by illness with financial and other kinds of support.

Health and social care systems have to work seamlessly together and share information with one another. Integrated data makes it easier to report on outcomes, to see what worked and what needs to be improved. Data can also be used to develop predictive and prescriptive analysis, helping advance care coordination and improving individual and population health and wellness.

By tapping all this health and social data, care organisations can observe and coordinate the connections between how people live and work within his wider environment as well as their lifestyle choices and other factors to improve individual wellness and vitality.

The Singapore Health Ministry's plan for a national database for the social services sector by 2015 is a great step forward in this direction.

It is easy to look at the evolving healthcare and social services environment as just another mandate for change in the care systems of society. Forward-looking leaders spot opportunities for bold transformations in how they manage, deliver and sustain care programmes. They understand that healthier populations do not just require more hospitals but a much more holistic approach to support the transformation.

Regardless of how the journey towards smarter, more collaborative and coordinated care begins, it should begin now. The investment in a healthier population will pay its dividend in the form of improved community vitality and lower healthcare costs in the long term. This is the most effective response to the challenge to do more with less.

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