Targeting High Utilizers of Health Care

SUMR Blog

Targeting High Utilizers of Health Care

A substantial part of the problem with health care costs can be attributed to a disjointed system that perpetuates inefficiencies, such as overreliance on emergency departments (EDs). According to a recent study, ED visits in metropolitan areas have risen 22% in the last five years.  Because of this dramatic shift in ED utilization, there has been a significant interest in the small portion of the population that uses these resources the most and account for the majority of health care costs. These patients are often referred to as “high utilizers.”

High utilizers are typically vulnerable populations with complex social components, high behavioral health needs, and multiple chronic conditions). The top 5% of individual utilizers account for about 50% of overall health care expenditures. Due to their complicated medical needs, these patients tend to heavily rely on ED facilities and are difficult to engage in ongoing care with primary care providers. ED use is more expensive to the health care system than going to a primary care physician.

To decrease costs and improve care, a number of health care interventions for high utilizing populations have looked to engage patients and provide them with needed support and resources. By realizing that improving health requires more than clinical care, interventions typically incorporate social services and education programs alongside the clinical approach. While these programs may require an increase in resources at the front end, the potential benefits of a decrease in health care utilization and improvements in the overall health of these patients may outweigh the initial costs and time needed to implement these programs. 

A number of studies have evaluated different types of care management interventions aimed at high utilizing patients. Typically, these interventions incorporate a telephonic nurse navigator to engage with patients. Telephonic nurse navigators remind patients of upcoming appointments, and try to make sure patients understand outpatient procedures. Success of these programs is evaluated using outcomes such as average number of hospital days and number of ED visits. Some studies have found evidence that particular interventions were successful in reducing health care costs; yet others have found no discernable decrease in these key measures. Even in studies that did not find a decrease in health care utilization or costs, they reported a number of positive “unanticipated consequences.” Positive consequences for high utilizers in these studies include an increase in patient satisfaction with their primary care providers and their overall health care experience. These high utilizers began trusting their providers because they reported feeling as though their providers took a genuine interest in their well-being. This has implications for helping shift patients from relying on EDs to creating long-term relationships with primary care facilities, possibly decreasing costs over time. 

One limitation with many of these programs is that they typically rely on telephonic interventions, instead of in-person ones. The nurse navigators are set up as an added safety net for calling patients to connect them more efficiently with appointments and social services. However, the lack of an in-person component can make it difficult to engage with patients. Another major limitation of previous programs is that they seldom engage patients with their behavioral health concerns. The majority of high utilizers have high behavioral health needs that often inhibit them from fully managing their chronic conditions.  A patient’s depression can often affect his or her ability to take their inhalers consistently for their asthma, or remember their insulin regimen for their diabetes. Further, past studies examining previous programs do not measure overall quality of life as an outcome. ED utilization and number of days in a hospital are important measurements, but they do not show the complete picture. To sustain reduced health care costs, there needs to be an emphasis on improving the overall health of high utilizing patients, and that includes the behavioral health side.

This summer I am working with Dr. Manik Chhabra on a project that is evaluating the impact of a Community Based Care Management (CBCM) program on high utilizing patients in Philadelphia. The program, which was implemented by a Medicaid Managed Care Organization, uses nurse navigators, community health workers, and integrates behavioral health resources. Unlike other programs, the nurse navigator and community health workers engage with patients in-person through the clinical setting, and also are able to make home visits to see what barriers exist within the home that may affect a patient’s clinical needs.  With the added emphasis on behavioral health needs, the program’s objective is to address the social and behavioral health needs of patients in order to decrease costs and increase health and overall quality of life. Our study looks to evaluate this program in a way that addresses a number of the limitations of previous studies. Most of these evaluations used quantitative analyses to measure the success of an intervention. However, by incorporating both a quantitative and a qualitative component, we hope to gain a more complete picture of the program’s impact. Quantitative analysis can evaluate hospital use and costs while the qualitative side can provide a richer insight into how the program was implemented, its effects on patients’ quality of life, and how similar interventions can be improved in the future. This study looks to identify those “unintended consequences” that aren’t as easily captured by quantitative analysis alone. By identifying the barriers and facilitators of a successful care management program, we can help guide future interventions aimed at high utilizing patients.