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Reporting on how, why hospital superusers account for bulk of health-care spending Date: 01/09/15

By Tim Darragh

My former employer, The Morning Call, of Allentown, Pa., in November published a four-day series of stories I wrote about a local effort to find ways to improve care and individual health while reducing expenditures for so-called “super-utilizers.” These patients constantly use expensive emergency departments for their health care needs – in many cases, poorly controlled chronic and mental health illnesses, coupled with social isolation, unhealthy living environments and poverty.

Your community might not have a federally-funded pilot program to address super-utilizers as Allentown has. But your community has superusers – and if your community is in the United States and is served by a hospital, it has similarities with Allentown that you can explore in your own reporting.

The Obamacare Effect

No matter what state you live and work in, the Affordable Care Act is putting pressure on the local health care system to squeeze out costs. Accountable Care Organizations, patient-centered medical homes and other programs are designed to do what the super-utilizer program seeks: Improve health with measureable best health care practices while spending less. These are terms that likely are inscrutable to your audience, but it’s a simple concept.

Find the underlying issues that drive so much expensive care. Addressing them, providers can reduce usage, improve health and save money. Super-utilizers in one sense are the low-hanging fruit of health care. They accounted for 1 percent of the health care users in Camden, N.J. – the home of the super-utilizer movement’s godfather, Jeffrey Brenner, M.D. – but 30 percent of health care spending. That ratio roughly holds up throughout the U.S.

Data is the lifeblood of the Brenner model. Since the program in Allentown was a start-up, it had no data during my reporting, but it will soon have preliminary data comparing patients’ hospital use before and after the program’s intervention. Ask for the data. If the program works as it has in Camden, the providers will be happy to share. It’s easy to see that improvement among some super-utilizers could reap significant financial benefits.

Who and where are they?

If my experience is an indicator, they are old and young, male and female, rural and urban. They came from the three main racial groups around Allentown – white, African-American and Latino. Everyone I interviewed either had chronic obstructive pulmonary disease (COPD) or diabetes or both. Some were dialysis patients. Some had mental health and substance abuse issues. All of these are attributes of super-utilizers in other communities. How do you find them? Talk to your local EMS. They see these patients daily. If they need dialysis, they will be at the local dialysis center three times every week. Go to your local advocacy organizations supporting diabetics and lung disease.

It also is very likely your hospital has some sort of program underway to make sure these patients stay out of their beds, because the federal government under the Affordable Care Act is penalizing hospitals for excessive readmissions, including those for patients with chronic lung failure.

Transportation

A common theme among the super-utilizers and experts I interviewed revolves around transportation woes. Dialysis and chemotherapy patients who qualify for subsidized transit in the Allentown area have to share rides with healthy elderly people who also qualify for subsidized rides. So a patient who has an appointment at a wound care center may have to get on board hours before his appointment because the transit bus driver first has to deliver riders to a shopping mall for hair appointments. Traffic delays, breakdowns and late-running doctor appointments also can wreak havoc on patients’ lives and schedules, especially if they are diabetics.

In rural areas, transportation might be impossible without a family member. Families and home caregivers inevitably get caught in the swirl of late arrivals or missed trips.

Soft skills

Not every program emphasizes the interpersonal and community aspects of wellness that the Allentown program does. But after spending months watching it, I came away convinced that for some patients, the part of its program designed to get them re-integrated into their community, church or even with other patients was vital and as important as their physical care. This part of the program might involve household visits, invitations to potluck dinners with other patients and integration in a time banking program, where an hour of a patient’s time cooking a meal might be traded for someone’s hour repairing the patient’s furniture.

Health care’s responsibility

It was eye-opening to see how the fee-for-service system drove a lot of super-utilizers’ behavior. It rewards providers for treating only immediate symptoms and then gave them room to blame patients for their ill health. I saw this myself, as one large health network, given clearance by a patient to discuss his care, blamed his repeated use of its hospitals not on its failure to properly treat his multiple problems, but on his failure to carry out their treatment plan. This, for a patient whose heart and lungs functioned poorly, had schizo-affective disorder, could barely walk and was living in poverty alone in a motel room.

If you don’t understand the issue of uncoordinated care, study these patients. You will see patients who receive plenty of health care that fails to make them better.

The patients

It was revealing to get to know patients and see how bad breaks – a chaotic childhood, an unforeseen health setback, a brush with the law – set them on the path of constant ill health. As patients who spend most of their time and energy staying alive, they dwell in society’s shadows. This also makes them a reporting challenge. Their records, if they have any, are usually a jumble of papers and notes. They’re sometimes difficult to track down, especially if their cell phone minutes are expired or they suddenly end up hospitalized. On the other hand, it seemed to me that a number of these patients appreciated that someone finally was listening to them.

This is why this is a story worth doing over time. (I reported this on and off for more than a year.) A reporter could drop in on a program and craft a nice story after a day of reporting. But you could get a great story following these patients over time, seeing their interactions with the system and then using powerful personal tales to illustrate one of the most dynamic issues in health care today – finding better care and better health, at less cost.

Tim Darragh is on the investigative/enterprise team at NJ Advance Media, which publishes The Star-Ledger and NJ.com. He wrote these stories while participating in the National Health Journalism Fellowship, a program of the University of Southern California's Annenberg School of Journalism.