For Many Patients Who Use Large Amounts of healthcare Services, the Need Is Intense, Yet Temporary

Johnson T, Rinehart D, Durfee J, Daniel B, Batal H, Blum J, Oronce C, Melinkovich P
Source: Health Affairs
Publication Year: 2015
Patient Need Addressed: Behavioral health, Chronic Conditions
Population Focus: Complex care
Study Design: Other Study Design
Type of Literature: White
link: https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2014.1186
Abstract

Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the healthcare system through less expensive community- and primary care–based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May 1, 2011–April 30, 2013. Our analysis found that consistently 3 % of adult patients met superutilizer criteria and accounted for 30 % of adult charges. Fewer than half of super-utilizers identified as such on May 1, 2011, remained in the category seven months later, and only 28 % remained at the end of a year. This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as superutilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.

Insights Results

Overview of article

  • This article seeks to address 4 study objectives: 1) Describing the chronic disease burden and social determinants of health at a population level; 2) Assessing the persistence of super-utilizer status at the individual level; 3) Quantifying cost trends over time under current care models; and 4) Identifying subgroups that are amenable to subgroup-aligned intervention strategies
    Methods
  • Clinical, demographic, and financial data on super-utilizers were extracted from the data warehouse of Denver Health, an integrated safety-net health system and the largest provider in Colorado of services to people in the state with Medicaid or no insurance
  • The study defined super-utilizers as patients who—during the study period, May 1, 2011–April 30, 2013—had 3 or more hospitalizations in a rolling 12-month look-back period or had both a serious mental health diagnosis and two or more hospitalizations in that look-back period
  • For the analysis, population characteristics were examined on a monthly cross-sectional basis. The authors focused on sociodemographic characteristics, per capita spending, payer mix, and health risk profile as assessed by predictive modeling tools. Patients identified as super-utilizers during May 2011 were followed longitudinally to quantify the persistence of super-utilizer status and patient mortality

Results

  • Study results demonstrate that clinical, demographic and financial characteristics of the population were relatively stable, indicating a stable burden. At the individual level, results show that super-utilizers cycled in and out of super-utilizer status on a monthly basis. Costs for super-utilizers were highest at baseline with spending in subsequent years being much lower. Finally, all subgroups of super-utilizers assess, except for terminal cancer patients and recipients of emergency inpatient dialysis, showed a reduction in spending in the year after identification as super-utilizers, compared to the year before. Reductions ranged from 28%-60%
  • This study adds to the literature that suggests that the vast majority of super-utilizers have multiple comorbid chronic conditions, including mental health conditions
  • Population-level stability may oversimplify the variation of the problem at the individual level and may affect policy discussions around this population. The individual level variation has important implications for program design as interventions that target high utilization may look different than those for individuals with time-limited episodes of super-utilization
  • Changes in super-utilizer status likely reflect multiple factors, including natural history of illness that flares up and then improves over time, the impact of care on course of disease, and mortality
  • The lack of clinically accepted, sensitive and specific methods of super-utilizer identification presents a practical barrier to developing aligned interventions
  • Study results can help to inform when, where and how to optimally intervene. For example, some super-utilizers do not have primary care attachments and thus, warrant a different consideration of location for care when compared to a patient with stable primary care access and availability
  • The high prevalence of mental health conditions and substance abuse that occurs with high medical need suggests a need for integrated care models. However, financing and delivery of mental and physical health services in state Medicaid programs pose a policy barrier
  • Limitations to this study include: 1) Limited generalizability to other or non-safety net populations; and 2) The analysis only partially captured super utilizer use that occurred outside the integrated delivery system

Key takeaways/implications

  • Moving forward, improved predictive modeling should aim to not only identify individuals who are likely to experience sustained levels of avoidable utilization, but also to better classify subgroups of patients for whom aligned interventions are needed
  • Key unanswered questions about program design and effectiveness include which patients can be effectively engaged in care, which use is modifiable, when services should be short-term versus ongoing, which patients benefit from which services, where the services should be based or delivered, and when payer approaches are preferable to provider approaches
  • Most existing programs have not been implemented under a research framework, such as a randomized controlled trial. Program evaluations that used strong observational designs would fill an important gap in the literature on the effectiveness of super-utilizer programs
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