Recommendations for Addressing the Needs of High Utilizer/Super Utilizer Patients in Michigan

Insights Results

Overview of article

• This article outlines recommendations drafted following a symposium around challenges of patients who use emergency services at high frequencies (5 or more visits in a 12 month period), specifically focusing on Michigan Medicaid enrollees. Discussions centered around 3 specific recommendation areas: 1) Addressing patterns of very high rates of utilization of emergency services; 2) Developing new models of payment that would promote greater effectiveness of care and improved outcomes; and 3) Addressing use of emergency services for health concerns that could be addressed appropriately in other healthcare settings, such as primary care and dental care
• 2 underlying challenges of what constitutes “overutilization of emergency departments” and “improper emergency service usage”: 1) Overutilization of emergency departments – a phenomenon that involves individuals with multiple health problems, often a combination of physical health and behavioral health challenges, and insufficient coordination of healthcare services and support across multiple healthcare settings including emergency departments, hospitals, clinics, and home care. Research indicates that such individuals and their high-utilization are known to respond well to efforts that focus fundamentally on care coordination and support in health and non-health (e.g., housing, education) settings; and 2) Improper emergency service usage – a phenomenon that reflects intertwined challenges of insufficient access to timely primary healthcare for problems that could be appropriately addressed in primary care settings and insufficient awareness by the public about which health problems are appropriate for which healthcare settings. Of note, there is no universally accepted list or designation of health conditions or circumstances that indicates “improper emergency service usage”

Key takeaways/implications

• Recommendations for decreasing overutilization of emergency departments and improper emergency services usage include:
• Recommendation 1: Establish a uniform set of terms: The goal of this recommendation is for Michigan Department of Community Health (MDCH) and other stakeholder organizations in Michigan to use a common set of terms to describe high levels of healthcare utilization. The combined term “high/super utilizers” is recommended to refer to all individuals within the groups meeting either the high-utilizer or super-utilizer definitions (i.e., ED high utilizer: 5-9 visits per year to any ED; ED super utilizer: 20 or more ED visits per year; inpatient high utilizer: 2-3 hospital admissions per year; inpatient super utilizer: 4+ hospital readmissions per year; behavioral high utilizer: combination of 3-4 hospital admissions per year OR 20-39 inpatient days per year in a psychiatric facility; behavioral super utilizer: combination of 5 or more hospital admissions per year OR 40+ inpatient days per year in a psychiatric facility). A uniform set of terms will permit clear points of reference in analysis and policy discussions, underscore differences in magnitude of needs for patients in these groups and facilitate the development of targeted programs to address the unique needs of individuals identified in these groups
• Recommendation 2: Establish a standing advisory council on healthcare utilization: The goal of this recommendation is to further address the needs of high/super utilizers as informed by a permanent standing Advisory Council to sustain and expand the activities of the working groups. The Advisory Council on Healthcare Utilization will be comprised of physicians, nurses, social workers, community health workers, patients, payers, healthcare organizations, public health professionals and health information exchange experts, at least 1 emergency physician and at least 1 practicing behavioral health specialist. The Advisory Council will be tasked with 1) Maintaining a high/super utilizer program clearinghouse to share best practices and insights from programs across the state; 2) Create/choose performance measures and outcomes measures; 3) Act as a hub for statewide public health efforts for high/super utilizer populations; and 4) Act as a connector to similar metropolitan and state-level efforts. The Advisory Council will also explore issues such as standards for primary care settings and urgent care facilities as opportunities to expand primary care access, and consider non-traditional services for Medicaid reimbursement to meet the clinical and social needs for high/super utilizers
• Recommendation 3: Support targeted development and deployment of health information exchange – The goal of this recommendation is to continue to support and encourage statewide health information exchange with specific goals of involving healthcare providers, community mental health, and community organizations in coordinated care of high/super utilizers. Health information exchange could be improved with adaptations of the state’s interpretation of federal regulations that facilitate universal release of information for behavioral health. Specific actions may include: 1) Permitting access by all licensed professionals involved in patient care; 2) Using a “push model” (avoid providers needed to query the system and use flags to alert providers to high/super utilizer); 3) Making available Admissions Discharge and Transfer feeds to all licensed facilities and payers; 4) Integrate with the Michigan prescription drug monitoring program; and 5) Linking patient-specific care plans to the Michigan Health Information Network (MiHIN) so that healthcare professionals can access a care plan at the point of care
• Recommendation 4: Reform payment to promote development and implementation of high/super utilizer programs by healthcare providers – The goal of this recommendation is to improve care coordination programs for high/super utilizers. Specifically, the Medicaid program should consider how its payment arrangement and contracts with Medicaid managed care plans align incentives for care coordination among healthcare providers. Educational programs should also be included to inform providers across the state about reimbursement opportunities and expectations. With such reform, there will need to be clear and concrete performance and outcome measures for care coordination
• Recommendation 5: Reform payment to promote development and implementation of high/super utilizer programs by Medicaid health plans – The goal of this recommendation is to develop and implement better care coordination programs for high/super utilizers by Medicaid health plans. Specifically, the Medicaid program should promote alignment of incentives for care coordination by Medicaid health plans in ways that do not duplicate those efforts of providers. With such programs, it’s important to consider social determinants of health like housing
• Recommendation 6: Broaden state resources to support innovation regarding high/super utilizer patterns – Specifically, Michigan should sponsor development, evaluation and continuous improvement of high/super utilizer programs that address topic areas like Behavioral Health Homes (as an analogue and companion to primary care medical homes), coordination of referrals for medical clearance related to inpatient psychiatric admissions, and models of timely data sharing of personal health information that facilitate care coordination and mitigate high/super utilizer patterns while protecting individuals’ personal health information. There is also opportunity for collaboration with the Advisory Council through this recommendation
• Recommendation 7: Encourage and support care coordination for high/super utilizers – Specifically, the MDCH should create and strongly encourage utilization of a uniform care plan, driven by what healthcare providers need to know in order to care for the patient; encourage facilities, providers and payers to embed care coordination for high/super utilizers at the emergency department level; and explore existing efforts, funding and models that are relevant to addressing the needs of high/super utilizers
• Recommendation 8: Implement statewide narcotic prescribing guidelines to reduce drug-seeking among, and drug-dispensing to, high/super utilizers and reduce inappropriate prescribing of narcotics – Specifically, the MDCH should call for implementation of statewide narcotic prescribing guidelines (e.g., leverage guidelines proposed by the Michigan College of Emergency Physicians), emphasize the use of such guidelines as rooted in patient health and safety, work with its stakeholder partners to educate primary care physicians and other providers, and strongly encourage healthcare providers to utilize existing systems (e.g., Michigan’s prescription drug monitoring program – MAPS) to reduce inappropriate narcotic prescribing
• Recommendation 9: Promote and facilitate continuous quality improvement regarding high/super utilizer healthcare in Michigan to ensure interventions are successful – Definitions of success with patient-centered metrics should relate to ED use and prescribing patters. Specifically, the MDCH and its Advisory Council should convene regular meetings of a Quality Improvement Working Group from various healthcare facilities, provider organizations and academic research units in Michigan to examine data from Michigan Medicaid and community-level initiatives in Michigan to understand how such initiatives are affecting care
• Recommendation 10: Increase access to primary care in Michigan by leveraging and building upon existing primary care infrastructure in Michigan (e.g., patient-centered medical homes, Michigan Primary Care Transformation) to heighten public awareness and appropriateness of seeking care in ED and non-ED settings – Specifically, the MDCH should ensure timely access to primary care to reduce population-level reliance on ED care for minor medical complaints, act to sustain primary care reimbursement through Medicaid in Michigan to ensure that primary care providers have incentives to continue to accept individuals with Medicaid coverage, and consider novel payment initiatives that would align incentives for timely primary care. Novel payments may include reimbursing at a higher rate through evening and weekend hours, reimbursing at a higher rate for a patient recently seen in an ED setting who is seen for follow-up in primary care, reimbursing at a higher rate for care coordination services, or incentivizing providers whose ED visit rates are lower than average. This recommendation must also consider the recruitment, training and expansion of primary care providers, especially those with high proportions of high/super utilizers
• Recommendation 11: Educate the public regarding appropriate use of healthcare at different levels of care – The goal of this recommendation is to educate the Michigan population about the levels of healthcare services that correspond to the severity and complexity of illness to assure the most appropriate level of care. Specifically, the state should examine evidence from programs that have been implemented elsewhere to encourage patients’ use of healthcare settings that correspond with the severity and complexity of illness. They should also encourage and evaluate programs that are implemented in Michigan keeping in mind that efficient healthcare must be paired with optimal patient and population health outcomes