Treating Super Utilizers in Rural Pennsylvania

A nurse runs a diabetes test on a patient.

A nurse conducts a foot exam on a diabetic patient in Oak Hill, W.Va.

Two years ago, Chris Echterling, MD, a family physician and medical director of WellSpan’s Bridges to Health, showed it’s possible to identify high utilizers, give them more care and reduce costs. WellSpan is an integrated delivery system of three hospitals in York and Adams counties and 500 physicians in Central Pennsylvania. Its Bridges to Health program aims to improve the care of high utilizers, meaning patients with many chronic conditions who require more care than most patients and thus consume a higher proportion of total costs.

Echterling’s data show that, similar to the findings of Jeff Brenner, MD, in Camden, N.J., spending for a small percentage of certain patients with chronic conditions is disproportionately high. In York and Adams counties, Echterling found that about 4 percent of high utilizers account for almost half of all spending. Through a grant from the Robert Wood Johnson Foundation, members of Echterling’s team have been to Camden to meet with Brenner and his staff, and Brenner has been to York as well. Moreover, Brenner and the coalition’s staff consult with Echterling and other providers involved in the WellSpan project. They also consult with staff running four similar initiatives in Pennsylvania. 

"We know that not everyone who visits the ER needs to get care in that setting," Echterling says. "The challenge is to learn how we can improve the quality of life for these patients but do so by caring for them in more appropriate ways and places."


Echterling’s efforts began in 2011 when he conducted a pilot study to identify high utilizers and then intervene to ensure that they got the care necessary to keep them out of the ER and avoid costly hospitalizations. “We looked for patients who have high costs resulting from frequent visits to the ER or frequent hospitalizations, or both,” he explains. “Our aim is to provide outstanding, safe, timely, effective, efficient, and equitable patient-centered care.”

For this pilot program, Echterling identified 12 patients who in the prior year had 99 visits to the emergency room, 62 inpatient stays, and 25 office visits. Over 12 months, costs for these 12 patients totaled $1.5 million.

Once these 12 patients were enrolled in the program, they received a team-based approach to care, meaning their primary care provider had access to behavioral health and social services and home health care assistance. After the primary care physicians worked closely with these patients, the annualized number of ER, inpatient, and observation visits dropped by 25 percent and total costs dropped by 28 percent to about $1.1 million, Echterling explains. (See table below.)

Upon seeing those numbers, WellSpan invested $1.3 million to expand the initiative, creating the WellSpan Bridges to Health program. The Bridges to Health team consists of a primary care physician, nurse case manager, health coach, social worker, and program supervisor.

This year, Echterling’s team is working to identify and provide care for high utilizers among residents of York and Gettysburg. About 14,000 of these people are WellSpan’s own insured employees and family members. Because WellSpan is self insured, any savings from lower use of health services in this population would benefit the organization itself. The remaining patients in the population are uninsured. A reduction in spending for this group of uninsured patients could save the health system the cost of their treatment since the uninsured often cannot afford costly care.

“As a nonprofit health system, WellSpan has limited resources. That makes all savings significant,” Echterling explains. “Because we’re learning how to provide care for patients who are high utilizers, in a sense we’re learning how to understand data and how to manage a population.

“We know there are people in the hospital who don’t need to be there, and we know that not everyone who visits the ER needs to get care in that setting. So, the challenge is to learn how we can improve the quality of life for these patients but do so by caring for them in more appropriate ways and places, thus using the community’s resources more wisely,” he says.

As a result of his work, a private foundation in Pennsylvania is investing in a larger effort to identify and treat patients considered to be high utilizers. This spring, the Highmark Foundation in Camp Hill, Pa., awarded a grant of $125,000 to WellSpan. The foundation’s grant helps fund the Robert Wood Johnson Foundation’s Aligning Forces for Quality-South Central Pennsylvania’s High Utilizer Collaborative, which includes not only the WellSpan Bridges to Health program but also four similar programs in Chester, Harrisburg, Lancaster, and the Lehigh Valley.

If Bridges to Health and the other four programs can demonstrate a reduction in health care utilization and costs, the foundation would use that data to promote the program’s success both within Highmark and to others as well, says Rosemary Browne, the foundation’s program officer. One of Pennsylvania’s largest insurers, Highmark Blue Cross Blue Shield established the foundation in 2000 but the two entities operate autonomously, Browne adds. Every six months, the foundation will examine the program’s results to see if they could be replicated in other areas where Highmark operates, including 29 counties in Pennsylvania and in West Virginia and Delaware as well, she adds.