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‘Super users’ under microscope in WellSpan pilot program

When it comes to health care costs, less sometimes really does mean more.
That’s what Dr. Chris Echterling and his colleagues found when they analyzed cost data from the 8,000 patients enrolled in Healthy York Network, a coalition of York and Adams county providers who care for the uninsured or underinsured.

“We got the blessing to come together and form a virtual team to do whatever is needed — even if it’s nontraditional, even if the involved components act in ways they won’t get reimbursed for — to see if (we’re able to provide) the same or better care at a lower total cost to health care system,” said Echterling, clinical director of Healthy York and of the York Hospital Community Health Center.

The six-month program, which began in February, enrolled 16 of the super users, all of whom incurred at least $3 million of bills in the past two years, Echterling said.

The 16 patients are receiving targeted interventions from the 15- to 20-member virtual team, which includes behavioral health, chaplaincy, home health care and social services providers, as well as more traditional medical personnel.

The 16 patients will be compared with an equal number of super users who are not receiving the targeted care. All providers have taken on the project in addition to everyday duties, with no extra stipend.

The diversity of the team points to the complexity and challenge of treating some super users, Echterling said.

It’s easy to see why some super users have racked up big bills — chronic diseases, cancer or kidney failure, for example. On the other hand, some patients’ records at first glance seem more baffling, such as one person visited the emergency room 20 times for headaches, he said.

But health care needs don’t exist in a vacuum, Echterling said. A patient’s poverty, lack of transportation and adequate housing as well as any substance-abuse or mental-health issues all can exert a powerful influence on outcomes.

Therefore, the teams will meet regularly to share data and create care plans for patients to try to address needs holistically. “(We’re meeting to discuss) what does this patient really need, besides prescriptions? We’re coming up with things like housing, food, mental health and substance abuse counseling or better communication,” Echterling said.

At recent meeting, team members moved to get a YMCA membership for a morbidly obese patient and scheduled a teleconference so specialists and a primary care provider could better collaborate on the care of another patient.

An additional challenge in treating these patients, which is intentionally sidestepped by the pilot, is reconciling these types of interventions with how the government reimburses health care costs, he said.

The government reimburses care on a fee-for-service basis, which means providers receive payouts based on procedures, not on outcomes, and some areas or procedures have a better reimbursement rate than others.

But because all the pilot enrollees are part of Healthy York, which is part of providers’ charity care, the reimbursement or lack thereof does not enter into the equation, he said.
One goal of the program is that the results will be applicable in the community and elsewhere, said Eve Gardner, the executive director of Healthy York Network.

“Every doctor has a patient he or she struggles to manage best,” she said.

Similar programs to identify and better treat super users, including some initiatives that have progressed far enough to proactively identify possible high-cost “hot spots,” are taking shape across the country.

Author and physician Atul Gawande profiled numerous efforts to address the issue in Jan. 24 issue of The New Yorker, leading with the multiyear efforts of primary care physician Dr. Jeffrey Brenner in Camden, N.J.

WellSpan brought Brenner in for a presentation about his work before starting their pilot, Echterling said.

Closer to home, Lancaster General Health has begun combing through both inpatient and emergency-room records to see who’s racking up the most visits, said Michael Horst, director of research for the health system.

The analysis focused on identifying the characteristics of the 10 percent of users who visited each setting most frequently; to simplify data collecting, the study only included people who receive primary care services through LGH.

On the emergency room side, the study found 18- to 39-year-olds were the most frequent users, with people over 65 being the least frequent, Horst said. Unsurprisingly, people who lived closer to the hospital were more likely to be frequent users of the emergency room.

On the inpatient side, patients were most likely to be 65 or older, and more likely to be men, Horst said.

LGH now plans to start a more intense study of the super users’ medical issues, said Alice Yoder, director of community health.

At the same time, the system plans work with the Lancaster Health Improvement Partnership, a coalition of providers in the community, about how to better care for those individuals.

“We’re really looking at ways we could utilize the health care dollar in the most efficient way,” Yoder said. “And at same time, we keep quality in mind and are looking at improvements.”

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