Last year at Meritus Medical Center in Maryland, where I am an emergency physician, a certain patient visited the ER 81 times. We have records of at least a dozen more patients like him, though none quite as extreme. One man visited the ER 65 times in 2012. Another visited 48 times. At least two dozen more patients visited the ER more than ten times last year, although for most of them the number was closer to 20 or 30 times.
These patients are part of the one percent of the U.S. population now known commonly as Super Utilizers. The collective healthcare expenditures for this one percent account for 22 percent of all U.S. healthcare spending, according to a Centers for Medicare and Medicaid Services bulletin released in July. Where is much of that money spent? In the emergency room.
If you look just at Medicaid patients, the numbers get even more startling: “Just 5 percent of Medicaid beneficiaries [account] for 54 percent of total Medicaid expenditures,” according CMS. And, among the top 1 percent, 83 percent have at least three chronic conditions. More than 60 percent have five or more chronic conditions.
Emergency physicians like myself see this problem first hand every day. The man who showed up to my emergency room 81 times last year was there on average once every 4.5 days. This man had (and continues to have) serious health conditions to deal with, chief among them being his cancer. But Super Utilizers typically have a range of social and economic issues to contend with, in addition to their purely health-related conditions. Many enter the ER as a result of problems tied to alcohol or drug addiction. Others are homeless or close to being homeless and simply have nowhere else to go. Whatever the issue or combination of issues, our healthcare system has been failing to truly manage those conditions – until recently.
Last year at Meritus Medical Center, the gentleman with cancer and more than two dozen others who were identified to be Super Utilizers were added to a nascent program aimed at reducing their visits to the emergency room. Not only did this mean developing ways to provide them more effective care for the various chronic conditions they exhibited, but it meant reduced expenditures for the hospital (Meritus Medical Center is one of Maryland’s so-called “Total Patient Revenue” hospitals, giving it an incentive to reduce costs and find more efficient ways to deliver care).
Our program is not alone. The changes sweeping healthcare have led many hospitals, hospital systems, and whole states to examine ways to reduce spending on Super Utilizers. In July, six states and Puerto Rico announced a collaborative pilot program to better coordinate services for these patients. An organization analyzed records for three major hospitals in Camden, New Jersey, and found that 1 percent of Camden’s patients generated 30 percent of emergency room expenses. Even worse, 20 percent of patients account for 90 percent of ER costs. A coalition of healthcare providers is now working on programs to reduce those visits. Similar initiatives are underway in states across the country.
At Meritus, the results have been very positive. The more than two dozen patients who were identified last year have so far seen a collective 61 percent decrease in the number of ER visits this year. The man who showed up 81 times last year has so far been to the ER nine times this year. What changed? Previously, hospitals like ours had little incentive to prevent these Super Utilizers from coming in. One ER doctor was quoted in a USA Today article on Super Utilizers as following a philosophy of “treat ‘em and street ‘em,” essentially doing the bare minimum and returning the patient out on the street to fend for themselves.
Our program and others like it now seek to coordinate care far outside the bounds of the emergency room. In Maryland, we can take advantage of the Chesapeake Regional Information System for Hospitals (CRISP) to look up procedures or tests our patients have had at other care facilities. If the patient had a CT scan or x-ray performed at a hospital in Frederick, we know about it in Hagerstown. Unfortunately this system doesn’t extend to Pennsylvania and West Virginia, both of which are just a short drive away (a nationally integrated health information exchange would obviously do enormous good). We also work with our hospital’s care managers to identify primary care physicians and other specialists to help manage our patient’s conditions. Sometimes this work extends to coordinating social services, such as drug and alcohol rehabilitation, and even things as simple as providing transportation back and forth from a doctor’s appointment.
Rather than treating and streeting, hospital care managers now coordinate and leverage resources throughout the community to manage a range of patients’ social, economic, and health conditions. This sort of partnership, between my emergency physicians group, the hospital, and other groups and organizations throughout the community, is essential to reducing the huge cost and burden these patients are putting on our healthcare system.