March 20, 2017


Stanford's Big Health Care Idea : How an unconventional team of doctors figured out how to provide high-need university employees with better health care, for less money. (Heather Boerner, April/May 2017, American Prospect)

When Arnold Milstein arrived at Stanford University in 2010 to create the Clinical Excellence Research Center, he already had several careers' worth of experience in medical innovation. He had been in private practice as a psychiatrist; founded a health care consulting company; examined the organizational structure of hospitals and private practices, poring over the data on the quality of health care; and applied what he learned to improve care for Boeing employees in Seattle and hotel workers in Atlantic City. The biggest lesson he took from all those experiences was that American health care was ill-serving the very people who needed it the most. He had come to Stanford to study ways to make health care work better.

Tall and slim, with a kind face and short hair cropped straight across his forehead, the sixty-seven-year-old Milstein explains the problem succinctly: "It's a 5/50, 10/70 world." That is, 5 percent of patients account for 50 percent of health care spending, and 10 percent account for 70 percent, whether they're insured privately or by the government. These high spenders are the sickest and frailest, patients Milstein calls the "medically fragile."

At Stanford, in sunny, health-conscious California, Milstein saw the same thing. As a member of Stanford's employee benefits committee, which oversees the university's self-funded health insurance plan, he knew that medically fragile Stanford employees were sucking up the vast majority of health care spending and straining Stanford's system, without many signs of improved health. He had a theory for why this was happening. The patients weren't the problem; the problem was that the health care system was treating them the way it treats everybody else.

Milstein also had a theory for how to solve the problem. What if you took the concept of an intensive care unit--a single location that pulls together all the personnel and technology needed to care for the sickest patients in a hospital--and applied it to patients who were well enough not to be in the hospital but a lot sicker than the average patient in a primary care doctor's practice? Some of these people are old and frail, but many are young, hold down jobs at Stanford, raise families, and coach Little League, even though they have one or more chronic illness, like diabetes, depression, or cancer. They are among the most expensive to care for not just because they are sick, but also because the health care system is inefficient and disorganized when it comes to taking care of their multiple conditions. Why not organize the care around them the way a hospital organizes all the nurses, doctors, and technology needed for patients in the ICU?

Posted by at March 20, 2017 5:43 AM