Health Care Saving by the Bundle - NYTimes.com

On a typical night in the emergency room, a patient shows up short of breath, suffering from emphysema or heart failure or maybe both, as well as diabetes and high blood pressure. Doctors and nurses administer inhalers to ease his breathing and diuretics to take off excess fluid, and admit him to the hospital. Over the next few days, interns and residents furiously adjust his medications and fix his diet. He is discharged with a stack of prescriptions. A week or two later, chances are good he'll be right back in the emergency room.

A 2009 study in The New England Journal of Medicine showed that among Medicare patients, 20 percent were re-admitted to the hospital within 30 days of being discharged. We call these chronically ill patients frequent fliers.

What goes wrong? Just about everything. It is estimated that up to 40 percent of prescriptions go unfilled, and even when they are filled, patients often fail to take the medications as prescribed. Before blaming the patients, remember that many have multiple conditions and juggle 5 or 15 pills a day. Regulating a diet is difficult even for well-educated and motivated individuals. The typical Medicare patient sees 7 doctors a year; those with five or six chronic conditions see up to 10. They might forget to make an appointment, or be unable to keep it. If they do see a doctor, they probably have only 15 minutes to cram in all the issues they need to discuss.

The sickest 10 percent of patients consumes 64 percent of costs. Real savings require changing the way we care for these chronically ill patients.
With one-third of total health care expenditures spent on hospital care and about 20 percent spent on physician services and specialists each year, this is where the big money is — and where it can be saved. Although the United States spends more than $8,000 per person per year for health care, that money is not evenly distributed. Half the population — mostly young people and healthy adults — consumes just 3 percent of costs, while the sickest 10 percent consumes 64 percent. Real cost control requires changing the way we care for these high-cost patients with multiple chronic conditions. In particular, it requires preventing the avoidable complications that land them in emergency rooms and hospitals again and again.

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http://opinionator.blogs.nytimes.com/2011/11/16/saving-by-the-bundle/?hp