Published in the November 2015 issue of Today’s Hospitalist
EVERY HOSPITALIST KNOWS THEM: Super-utilizers, those patients with multiple chronic conditions, frequently combined with behavioral or mental health problems, who cycle through EDs and inpatient units for years on end. Or do they?
New research by Denver Health, a major safety-net system in Colorado, challenges stereotypes about frequent flyers in two important ways. For starters, the proportion of the patient population that qualifies for high-utilizer status is fairly steady over time. But it turns out that the individuals in that group change frequently.
“It was surprising how quickly people turn over in this population,” says Tracy Johnson, PhD, Denver Health’s director of health reform initiatives. “You don’t really have a stable group of people who are super-utilizers.”
“Your opportunity to intervene is really short.”
Published in the August issue of Health Affairs, the findings suggest that one-size-fits-all interventions will not work to solve the frequent-flyer problem every health system faces. They also point to how time-sensitive treatment is for these patients.Moreover, a significant minority defies the multiple chronic-condition stereotype entirely. As a group, these patients “who are suffering from terminal cancer or other acute conditions “rack up higher costs than super-utilizers with chronic conditions.
Episodic high utilization
Denver Health is the largest provider of health care services for Coloradoans who are uninsured or covered by Medicaid.
Dr. Johnson, the lead author of the study, received funding from the Center for Medicare & Medicaid Innovation to study Denver Health’s high-utilizing patient population. She conducted her research while interventions were being developed to improve those patients’ health status and reduce the cost of their care.
The research team defined a super-utilizer as having three or more hospitalizations or both a serious mental health diagnosis and at least two hospitalizations during the previous 12 months. They identified 4,774 super-utilizers, most of whom were either uninsured or publicly insured, during a two-year study period in 201113. Taking a group identified in May 2011, the research team compared those patients’ hospital utilization for the year before the study to the year after.
Researchers found that super-utilizers accounted for just 3% of the adult population but 30% of total charges, excluding professional fees, during the study period.
Separately, the authors calculated how many (and which) people met super-utilizer criteria for each of the next 24 months. That translated to about 1,650 people on average meeting super-utilizer criteria each month.
However, only 6% of those who met super-utilizer criteria at the beginning of the study maintained that status every month for the entire two years. More than half of the super-utilizers identified in the study’s first month had died or no longer met the criteria seven months later. While many patients cycled in and out of super-utilizer status across the 24-month study period, only 14% of those identified when the study began were still in that group when it ended.
“That small group of people who are consistently high-utilizing or intermittently high-utilizing is more the exception than the usual,” Dr. Johnson says.
That finding highlights the importance of real-time data and interventions targeted when super-utilization first begins to take place. As Dr. Johnson explains, because billing data can take several months to process, they are of limited value in identifying super-users who can benefit from special programs.
“Look at how many super-utilizers “as identified through billing data “aren’t going to be super-utilizers by the time they are referred into a program,” she points out. “Your opportunity to intervene is really short.”
Denver Health developed a two-pronged strategy to target high-utilizing patients with multiple chronic diseases or serious mental health diagnoses. First, they added staff to primary care clinics to follow up with super-utilizers quickly after a hospital discharge.
“This enhanced-care team includes nurse care coordinators, clinical pharmacists, behavioral health consultants, social workers and patient navigators,” Dr. Johnson explains. “Patient navigators, for example, go through a script and connect patients with clinic-based resources and get patients in for follow-up appointments with their established primary care providers.”
The health system also created a new intensive outpatient clinic specifically for high-utilizers, especially those without an established relationship with a primary care provider. This clinic also has enhanced staffing and offers longer, more frequent office visits.
“Nearly half of our super-utilizers weren’t using primary care regularly,” says Dr. Johnson. The research team’s conclusion: the way primary care is designed for a general population doesn’t work for super-users.
But not everyone who meets super-utilizer criteria is right for primary care-oriented interventions. Dr. Johnson discovered that nurses at the intensive outpatient clinic went through each day’s patient roster and culled those who were obviously not going to be well-served by extra primary care services.
“They look at the main thing driving patients’ utilization,” says Dr. Johnson. “If you’ve had complications related to orthopedic surgery, you’re not appropriate for their team. They also screen out people receiving active inpatient cancer treatment.”
That prompted Dr. Johnson to dive back into the super-utilizer data and look at the patient population through a new lens. The surprise finding: Eighteen percent of the super-utilizers at the beginning of the study fell into one of four subgroups. Those included patients receiving emergency inpatient dialysis, terminal cancer patients, trauma patients and orthopedic surgery patients suffering complications.
“High-service use is not synonymous with inappropriate service use,” she says. “People with cancer need a different kind of intervention. That utilization is driven by a different set of factors than a primary care-based intervention can address.”
Another interesting finding: The 18% of patients in the four subgroups accounted for 27% of the total acute-care costs accrued by all the super-utilizers in the first year after they were identified. That’s because the costs for patients in some subgroups were dramatically higher than for those with multiple chronic conditions and/or a serious mental health diagnosis.
While there were only 11 terminal cancer patients receiving inpatient treatment in the super-utilizer group, for instance, they accounted for $682,176 in average per-person spending in their first 12 months post-identification. That compares to between $62,600 and $77,833 in average per-person spending during those same 12 months for 82% of patients with multiple chronic diseases and/or a significant mental health issue.
Data for program design
Dr. Johnson points out that the high-utilizing subgroups identified at Denver Health might not be the same as other health systems will find. She encourages other hospitals that wish to develop programs for super-users to start by analyzing their own data.
Decide on a definition of super-utilizer “Dr. Johnson’s definition is one of many “and then start digging. “Data mining,” she says, “is very helpful when it comes to designing a program.”
Lola Butcher is a freelance health care writer based in Springfield, Mo.