If, like most people, you believe that “super-utilizers” are chronic abusers of the health system and that by getting these people in programs to help them manage their illnesses you can save your facility a ton of money, a new study may change all that.
Researchers at Denver Health — a facility that serves many uninsured and underinsured patients — found that super-utilizers (defined as people who use a large share of health care resources due to multiple chronic conditions and often have social or behavioral health risk factors) aren’t the frequent fliers they’re believed to be.
The study, which was recently published in Health Affairs, found the accepted belief of “once a super-utilizer, always a super-utilizer” isn’t 100% accurate. In fact, many patients who use healthcare services intensely do so for a relatively brief period of time.
The study, which was funded by a grant from the Center for Medicare & Medicaid Innovation (CMMI), examined the characteristics and costs of 4,774 publicly insured or uninsured patients who were hospitalized more than three times during a 12-month period between May 1, 2011 and April 30, 2013.
What they found was 3% of adult patients consistently met super-utilizer criteria and accounted for 30% of healthcare costs. However, fewer than half of the super-utilizers were in the category seven months later, and only 28 percent (1,682 patients) were in the category at the end of a year. And at the end of two years, only 14% were in the category.
Not to mention the fact that per person spending went down with decreased use of healthcare services, according to Kaiser Health News. It went from a baseline $113,522 per capita to $47,017 in year two.
These results were surprising even to the researchers. Why?
Because that means super-utilizers aren’t the same patients over time and many of them, while they have high usage periods, are relatively short in duration.
Assumed characteristics not found
Another important finding of the study was on an individual level, the typical characteristics most people assume super-utilizers have, such as multiple chronic conditions, weren’t reflected in the study.
While a substantial 42% did have multiple chronic conditions, others didn’t.
For example, 41% were hospitalized primarily due to serious mental health diagnoses. Other smaller numbers were hospitalized for orthopedic surgery, trauma, terminal cancer or for emergency inpatient dialysis.
Previous studies may have overlooked these clinically important subgroups of super-utilizers identified in this study. And these subgroups may respond to different approaches that would help prevent avoidable healthcare use. So a one-size-fits-all program isn’t the answer to reducing the healthcare cost impact of super-utilizers.
“We have used these in-depth analyses of Denver Health patients who have experienced multiple hospitalizations to implement unique population health services tailored to their specific health and social risk profiles,” Dr. Tracy Johnson, director of Health Reform Initiatives at Denver Health and the study’s lead author, said in a PR Newswire release.
“This includes establishing a new primary care clinic that exclusively serves medically complex adults, as well as adding new staff to follow up on hospitalizations and help support on-going care needs. This enhanced care team includes nurse care coordinators, clinical pharmacists, behavioral health consultants, social workers and patient navigators.”
Improved predictive modeling and programs
While this study sheds a new light on super-utilizers, more research is needed to better classify subgroups of patients and what interventions work for each group.
According to the researchers, this will require a blending of automated methods and clinical screening approaches.
Program design and the effectiveness will also need to be looked at. For example, in addition to primary care-based outreach efforts, alternative models need to be look at. One such model is ambulatory intensive care, in which complex and high-cost patients are selected to get primary care in an intensively resourced clinic.
Plus an integrated model that includes mental and physical health services is important, however, separate financing and care deliver in many Medicaid programs pose a barrier to this.