Next time you visit the doctor, look around the waiting room. If it's a crowded room, there will likely be four distinct groups of patients.
The first group is people who are relatively healthy, patients who want to see the doctor for an annual physical or a minor episode of illness or injury. The second group is made up of those at risk of a major medical episode that ultimately may require a hospital stay. These patients might be under treatment for cancer or a heart condition. The third group lives with a chronic condition, or even multiple conditions like diabetes or pulmonary disease. Some may be living under difficult circumstances that are not necessarily temporary, such as poverty, a disability or mental illness. And the fourth group is nearing the end of life. They have ailments and symptoms that accompany longevity.
The average cost of taking care of patients in the waiting room is approximately $8,000 per year. Those in the “healthy” group probably cost about $1,600 a person per year. Those who experience major episodes of illness or injury may cost upwards of $60,000 a year. Patients with one chronic illness cost $6,000 per year, those with two conditions cost $12,000 per year, etc. And those nearing the end-of-life have variable health expenditures, depending on individual healthcare challenges.
Under provisions of the Affordable Care Act, the team of healthcare professionals on the other side of the waiting room door is “accountable” for the health of all the people in the waiting room, and soon will be expected to assume financial risk for the cost of providing their necessary care. If everybody in the waiting room is healthy and each patient costs roughly $1,600 per year, the math works in favor of the healthcare team. Even if we add in several patients with a single chronic condition, the math continues to be favorable.
But what if a majority of patients in the waiting room are experiencing major episodes of illness or injury, or a majority are living with two or three chronic conditions? That average of $8,000 per patient is not nearly enough to cover all the healthcare services these patients require.
For the math to work, the waiting room needs to be large and diverse enough to have a balance of patients: the healthy, those dealing with major episodes, people dealing with chronic illness and those near the end of life. In part, this explains why many hospitals and physicians are combining their “waiting rooms” and teaming up to form large healthcare delivery organizations—they need to create a very large “virtual” waiting room that accommodates hundreds of thousands of patients.
We cannot create these large and inclusive waiting rooms absent regulatory protections. The embedded economic incentive is to populate the waiting room mostly with patients who cost $1,600 per year, by locating access points in geographies associated with healthy and affluent populations—and moving away from geographies where the poor and elderly reside. The resulting disparities in access and outcomes for vulnerable populations are a free-market certainty.
We need to think differently about the “accountable” healthcare team. There is no single type of physician —primary care or specialty care, hardworking, entrepreneurial and intelligent as they may be—who is capable of concurrently serving all four groups in our respective waiting rooms. Each requires a specialized team, composed of individuals uniquely qualified and technology-enabled to serve patients as they move in and out of the four groups, as they experience different states of health, and as they progress through various stages of life.
Today, thanks to technology, hospitals and health systems are blessed with a trove of information (including data from electronic health records, insurance claims and census tract demographics) to help them get a better handle on their patient populations. All of this knowledge will empower leaders to develop new and better care-management models to serve individual healthcare needs—for whoever shows up in their waiting rooms.