By Joseph Burns
Chris Echterling, MD, knows the problem well. A family physician and medical director for WellSpan Bridges to Health, in York, Pa., Echterling has seen many poor patients with multiple chronic conditions who lack access to a regular source of primary care.
Without access to primary care, these patients too often go to the nearest hospital emergency room, he says. By law, emergency rooms must treat all patients and so these patients become frequent users of the most costly settings in health care. Sometimes called super utilizers or high utilizers, these are the few patients who have so many ER visits and hospital stays that they account for a disproportionately high share of overall spending. Echterling’s data show, for example, that about 4 percent of high utilizers in York and Adams counties account for 49 percent of all costs.
Funding to intervene with high utilizers is scarce. “There are no billing codes for this," says Brenner.
“Treat and street,” is the expression hospital staff members have used in the past to describe the care these patients receive. It means give them what they need and send them on their way. But health care is changing as hospitals administrators, physicians, and insurers recognize that simply treating a person's symptoms during an ER visit does not solve that patient’s underlying problems. Instead, Echterling and health care providers in Massachusetts and Ohio are studying whether programs that address high utilizers’ fundamental social, behavioral, and health care needs can provide a return on investment—and health insurers have noticed.
In Cleveland, Ohio, a health plan and a commercial insurer are studying whether delivering more care to high utilizers in a county hospital can reduce costs overall. In Massachusetts and Pennsylvania, health plan-sponsored foundations have awarded grants to teams of providers running programs for high utilizers. Once they evaluate these programs, the foundations will publish the results so that health plans and provider organizations in other communities can consider implementing these ideas.
Each of these programs is adapted from the work of the Camden Coalition for Healthcare Providers and its executive director, Jeff Brenner, MD. The coalition is one of the best known initiatives for high utilizers. While the coalition’s efforts have successfully reduced ER visits and inpatients stays among high utilizers, similar programs in other cities have failed, Brenner said in an interview on the PBS show Frontline. Funding to intervene with high utilizers is scarce. “There are no billing codes for this. There’s no way currently to bill insurance or to bill Medicaid or Medicare for the kind of care that a team like this delivers. Other people have tried this, but it’s just very hard to get sustainable funding for this kind of work.”
“Treat and street,” is the expression hospital staff members have used in the past to describe the care these patients receive. It means give them what they need and send them on their way.
The search for sustainable funding makes the efforts in Massachusetts, Ohio, and Pennsylvania worth watching. If they can show that providing more care reduces overall costs, they may attract interest from health plans and accountable care organizations seeking to deliver care more efficiently to high-cost patients. In addition, two of the programs featured here are funded under grants from the Aligning Forces for Quality (AF4Q). The Robert Wood Johnson Foundation (RWJF) provides funding for AF4Q and the Camden Coalition. RWJF is funding efforts aimed at high utilizers at six sites: Boston, Cincinnati, Cleveland, Maine, Western Michigan and Humboldt County, Calif.
RWJF Program Officer Susan R. Mende praises the work with high utilizers. “These organizations address patients’ needs that are normally beyond the reach of the health care system,” Mende says. “They are mobilizing community service organizations to support patients who may need housing, transportation, or other social services.
“Second this work shows how health systems can use data to identify patients in need and how much these patients cost the system,” she adds. “Despite the high costs we pay for high utilizers, they still get poor health outcomes. So the data show a clear need to address this problem.
“Third this work illustrates disparities in how health care is delivered to low income people who have multiple medical, behavioral, and social problems,” Mende says. “Often these patients have complex needs that prevent them from getting the best care or that result in uneven or inconsistent care.
“And, the fourth reason this work is significant is that it has the potential to demonstrate how we can move high utilizers from getting uneven and inconsistent care to the point where they have a connection to the primary care system where nurse case managers and other providers can help them navigate the health system to get the care they need while also potentially limiting what we spend,” she explains.
Joseph Burns is a health care writer in Falmouth, Mass.