Health care’s costliest one percent of all patients are responsible for twenty percent of all spending, while the least costly 50 percent account for only three percent. Agency for Healthcare Research and Quality analysis reveals that the one percent are more likely older white females covered by private insurance and afflicted with at least one – but probably multiple – chronic conditions. Cancer, diabetes and heart disease aren’t just killing us, they’re murdering the health care cost equation.

As health reform talk shifts to buzzwords like ‘medical home,’ ‘health care navigators’ or ‘accountable care organizations (ACO’s),’ remember the one percent. A life challenged by co-morbidities requires lots of care, and according to analysts their particular care is so dramatically lacking in coordination that costs are out of hand. Entities like the VA, Geisinger and Advocate have proven that medical homes, navigator programs and ACO’s done right can score a hat trick: (1) lowering treatment costs by 20 percent or more, (2) improving practice revenues and (3) improving patient quality of life and satisfaction.

Hat tricks are crucial. Given the system’s inter-relational complexities, intended positive changes can trigger unintended negative consequences. With lives, livelihoods and economic competitiveness at stake, the devil is in the details, and particularly in improving relationships – between and among people and information. Where do we go next? As hockey great Wayne Gretzky would advise, we’ve got to “skate to where the puck is going, not to where it is now.” To address health care’s costliest one percent, that translates to better, more accountable care coordination.