|Want to bend the cost curve in any community?
How do you start a revolution? Great press helps. In the Jan. 24, 2011 issue of The New Yorker magazine, famed physician-writer Atul Gawande published “The Hot Spotters” which profiled Jeffrey Brenner, MD, a family physician (and 2011 CFHA conference plenary speaker) who was dramatically lowering healthcare costs in the impoverished city of Camden, NJ through engaging “super-utilizers”—that city’s most frequent users of hospital and emergency room services. As depicted by Gawande, Brenner was a zealous and persistent reformer with a simple point: Five percent of patients nationally generate 50% of all healthcare costs; if you want to bend the cost curve in any community, decreasing the excessive utilization of the most psychosocially and medically complex patients is the best first step.
With its stories of patients with multiple illnesses and chaotic lives making significant turnarounds, the article was an electric spur to action. State and national legislators took notice. Funders stepped up with monies for existing initiatives. And health systems around the country—nervous about the coming shift in healthcare financing toward cost-containment--immediately began experimenting with super-utilizer pilots in their own backyards.
Now, 4 years later, we have an initial, detailed progress report by an early and ambitious group of Brenner-inspired programs. The Highmark Foundation-funded South Central Pennsylvania High Utilizer Learning Collaborative—consisting of the Crozer-Keystone Health System (where I help lead the super-utilizer team), Lancaster General Health, Neighborhood Health Centers of the Lehigh Valley, PinnacleHealth System, and WellSpan Health—has recently published “Working with the Super-Utilizer Population: The Experience and Recommendations of Five Pennsylvania Programs,” a white paper on their collective experiences.
Written primarily by Widener University healthcare business professor Caryl Carpenter, M.P.H, Ph.D., the 77-page document captures the struggles and triumphs, nuances and diversity of interprofessional team-based super-utilizer care. In essence, it describes how 5 geographically close but disparate health systems have taken Brenner’s original vision—using data to segment patient populations and then develop intensive intervention strategies—and creatively adapted it to their local conditions and cultures.
|Three of the programs decreased hospital admissions for 138 patients by 34 percent--savings to payers of $1.1 million
Among the report’s highlights:
--How to define who is a super-utilizer (generally a patient with 2 or more hospital admissions in a 6-month period), including common social determinants of utilization;
--Tools for assessing super-utilizer patients’ psychological and social backgrounds and motivation for change;
--Different models of interprofessional team composition and functioning (including different approaches to whether the super-utilizer team provides primary care or only comprehensive care coordination);
--Similarities and contrasts between super-utilizer programs and Patient-Centered Medical Homes;
--Challenges of and strategies for engaging patients who are mistrustful of healthcare professionals or unwilling or unable to change their habits and circumstances;
--Strategies for partnering with other community-based healthcare and social service agencies to empower patients to take control of their own lives and health;
--Policy recommendations for state agencies and public and private payers;
The white paper also reports mostly impressive outcomes: Three of the programs (for whom data was available) decreased hospital admissions for 138 patients by 34 percent--savings to payers of $1.1 million. On the other hand, these same programs saw a slight rise in emergency room admissions for the same patients. And the rate of patients who dropped out of the programs because of lack of engagement or other factors was relatively high—over 30%.
What are at the heart of this document, however, are the same kinds of patient stories that Gawande documented. There is a short depiction of Bill, a homeless man in his 50s with cardiomyopathy and congestive heart failure, who had 25 inpatient and 6 ER admissions in a 6-month period. While in the PinnacleHealth program, his admissions decreased to 5 ER visits and 1 hospital admission during the next 5 months. There is the story of Robert, a 29-year-old man with Type 1 diabetes and chronic depression who had 12 inpatient and 15 ER admissions. Under the care of the Lancaster General Health program, his inpatient utilization decreased 50% and he had no further ER visits.
This white paper is a well-produced snapshot in time of an evolving approach to lowering healthcare costs. For as much of this territory as it describes in detailed narratives and charts, it also raises many key questions: How do we engage complex patients and empower them so that they eventually don’t need intensive team-based interventions? How do we make the transitions from PCMH to super-utilizer care (and back again once high utilization has decreased) as seamless as possible? How do we devise the most effective and sustainable teams? These questions will be answered by the calculated tinkering of these 5 programs and dozens of others around the country which regard reducing high utilization as an essential component of transforming American healthcare.
Barry J. Jacobs, Psy.D. is the Director of the Behavioral Sciences for the Crozer-Keystone Family Medicine Residency and the lead faculty member for its super-utilizer program, the Crozer Connections the Health Team, and the Camden-Cooper-Crozer Hot-Spotting and Super-Utilizer Fellowship Program. He is also the author of The Emotional Survival Guide for Caregivers (Guilford, 2006).