Why Health Care Needs to Focus More on the High-risk Patients in Value-based Care?

45-year old Jerry Rodríguez, a resident of Nebraska, has had a tough life. He faced an almost-terminal heart attack when he was 34 and was diagnosed with congestive heart failure and atrial fibrillation. To make matters worse, his health conditions were so irregular, he couldn’t hold a steady job. By 2012, though he had a dingy studio apartment rented on his name, he pretty much lived in different emergency departments. That year, he visited the ED 17 times and was admitted to the hospital 14 times.

This is just a story of one of the many high-risk patients, the frequent fliers in the US. It’s not just healthcare; every field has them. In fact, these are the real users of the system. These frequent fliers are a major part of the 5% who consume the 50% of the healthcare costs. How do we manage the rising costs in this emerging value-based era, and not leave the high-risk patients behind?

Emergency departments: the new haven

Much of the rising healthcare costs can be traced back to unnecessary emergency department visits. According to a study, the US healthcare spent a little over $47 million on ED visits, and this was way back in 2010. Now that the number of ED visits in the US has risen to 136.3 million every year, this cost is bound to increase!    

Often, frequent fliers among high-risk patients come into the emergency department as if it’s their second home. Although frequent fliers account for only 8% of all ED patients, they represent up to 28% of all ED visits. Some of them may have a serious chronic condition like a heart problem or cancer, and for them, the ED may be the best facility to provide them with urgent care. For some, ED is the only reliable source of healthcare since they lack access to a primary care physician, or other facilities may be too expensive.

Besides, the issue here is not irregular visits. The traditional emergency department is designed to provide urgent care. Patients are assessed, the appropriate treatment is decided, and ultimately, the patient is either admitted or released. EDs are particularly not designed to provide patients coordinated care. The lack of a designated PCP and hardly coordinated care are only some aspects of a larger problem.

Perhaps the reason is no insurance?

There is a widespread belief that emergency departments are flooded with uninsured patients for non-urgent health needs. While that is understandable, it’s not entirely true. The uninsured population is only a small subset of the overall frequent fliers.

Research suggests that uninsured population are not more likely to visit the ED than the insured. The uninsured are responsible for about 14% of total ED visits and about 12% of the overall ED expenditures. In fact, a significant percentage of the frequent fliers are the chronically ill and the Medicaid patients. The reason behind this hike is, again, the lack of access to primary care and unfortunately, the lack of knowledge of where to seek proper care.

From ‘frequent-fliers’ to ‘super-utilizers’

In all honesty, ‘frequent fliers’ are often assumed to be the problem patients- the ones labeled as ‘drug-seekers’ and ‘treatment resistant.’ Frankly, I believe they are a reflection of our ability to manage high-risk patients and address their needs. It’s not necessarily an issue with the patient. The mere image of these patients being ‘frequent fliers’ encourages disrespectfulness and plague good diagnostic judgment- the outcomes of both cases being placing the patient at the risk of a poor outcome, especially when the treatment could be interpersonally sensitive.

Recently, the term ‘frequent fliers’ is starting to be replaced by a more proactive ‘super-utilizers.’ This term gives a sense of well-intentioned shortlisting that automatically lets providers understand that a particular patient is a high-risk one, and requires a deeper examination of utilization. If we take behavior healthcare technology in consideration, bringing the term ‘super-utilizers’ could limit stigmas and negative outcomes. 

Fixing healthcare’s super-utilizers

Yes, replacing the term alone won’t work. The strategy has to be focused on optimizing the highest utilizers and costliest patients. Here are some steps that healthcare organizations can take to fix the issue with high-risk patients:

1. Understand patient population: Providers need to have a closer look at their patient population and should be able to stratify the ones at risk. There are several models like the Hierarchical Condition Categories (HCC), Adjusted Clinical Groups (ACGs), Elder Risk Assessment (ERA), and Chronic Comorbidity Count (CCC). Even predictive modeling tools can be helpful in assessing the patient population and understanding the impacts of certain anomalies and their future implications.
2. Leverage health IT: In order to understand population better and gain a closer look at the patients, health IT can be a useful tool. Health IT could help bring disparate data systems together and quality data into healthcare. This could be leveraged to create single, unified patient records where risk scoring and predictive algorithms can be run. Health IT platforms could be used to pull out the necessary information, clinical records, disease registries related to a particular patient- allowing better decision making at the point of care.  
3. Manage population health: Population health management may be a comprehensive term and every provider will have their own strategies on how to reduce ED visits. But a smart population health management strategy that looks after the healthy, the rising-risk, and the high-risk patients. Plus, it has to be ensured that these patients are navigated across the continuum to keep their conditions in check and reduce healthcare utilization.
4. Encourage the adoption of primary services: One part of reducing unplanned visits from super-utilizers is making sure they have a primary care facility they can go to for routine care. That way, even if they are in an ED for urgent care, they can always be referred to a facility or go to a PCP for routine follow-ups. 
5. Social determinants integrated with care: Healthcare is too vast to be narrowed down to a certain number of drivers casting their impact on overall population health. By integrating social determinants, connecting patients, and undertaking a multi-pronged approach to care, we can avoid the constant cycle of patients finding themselves constantly in EDs and meeting their needs.

The road ahead

Reducing ED visits to 0, or cutting down readmission to 0%, or making sure no one seeks urgent care too often is not a plausible goal. The goal is much larger than optimizing utilization metrics or reducing the cost of care. The goal to ensure that patients who come in, either for a regular visit or an emergency visit, are going to stay healthy- or at least, are on the path to recovery.

Super-utilizers are nothing but a group of patients who need extra attention, the high-need, high-risk patients, and it’s the responsibility of every healthcare professional to connect with them, encourage them to adopt a healthy living, and lead them to a better tomorrow. And if one ACO can work on this strategy to cut down their ED utilization by 6.65% and reduce their readmission rates by 7.14%, so can you! 

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This blog has originally been authored by Abhinav Shashank.