Financial executives at hospitals and health systems know how desperately their organizations need to reduce the cost of care going to "frequent fliers." In the United States, 5% of the population uses 60% of the healthcare resources, mainly through the overuse of emergency room visits and inpatient hospital stays, according to the Robert Wood Johnson Foundation. Much of this care could be delivered in less expensive settings and some of it could be avoided entirely through better provider coordination and outpatient follow-up.
For Jeffrey Brenner, MD, current treatment protocols of super-utilizers, as he calls this group, are vastly inadequate both clinically and financially.
Brenner is the founder and executive director of the Camden Coalition of Healthcare Providers and the medical director for the Urban Health Institute at Cooper Hospital, both in Camden, NJ, one of the poorest communities in the country. Since starting out as a family physician in a solo practice in Camden over a decade ago, Brenner has become increasingly focused on patients who use a disproportionately high amount of hospital and ER services.
"Everywhere I have looked, I see the same basic rule of thumb ... a small portion of the population is driving all the [healthcare] costs. It's a basic law of human systems that a small number of people drive many of the problems," Brenner said during a recent speech at the Maine Hospital Association's annual conference.
Brenner noted that the top reasons for ER visits among super-utilizers include basic, non-acute issues: head colds, ear infections, sore throats, headaches, and other non-emergent health concerns. "We are occupying emergency rooms with things that don't need it," he said. "It's a cash cow. It's the best thing in the world for ER docs."
But it's not the best thing in the world for patients or for taxpayers who foot much of the bill through Medicare and Medicaid—most super-utilizers being eligible for benefits under both entitlement programs. This dual-eligible population is "the most expensive subset of patients in the country," said Brenner.
By analyzing the medical records from the three major hospitals in Camden from 2002 through 2011, Brenner found that 1% of the city's patients generated 30% of emergency room expenses and that 20% of patients were responsible for 90% of ER costs. Not surprisingly, these extremely high-cost patients were predominantly dual-eligibles.
Brenner has identified several drivers that lead to a person becoming a complex healthcare consumer, including blindness, deafness, physical immobility, co-morbidities, a low literacy level, a lack of family support, not owning a car, addiction, and mental illness. Having several of these risk factors often makes a person an "extreme user" of healthcare, he said, noting that "the ROI is with finding expensive patients who are willing to change, and that's hard to do."
"There are no easy answers for these complex patients," Brenner concluded, encouraging the audience of mainly hospital administrators to embrace the challenge of finding better means of caring for this difficult patient population.
In a follow-up interview with Brenner, I asked him about the issue of complexity—both in terms of super-utilizer patients' health problems and the healthcare system that so far appears to be failing them and costing the rest of us billions of dollars in the process.
"We are talking about an incredibly complex system, and part of the problem is there is a huge asymmetry in knowledge," he said. "It's much easier to figure out if you like a car than if you like a surgeon. And the sickest and most complex patients—the most expensive people—often don't have the mental faculties to be informed consumers. ... I think with the science of complexity, you have to break the problems down into small pieces and do it in a patient-centered way."
The current healthcare system makes the mistake of putting these highly complex patients through the same paces as the rest of the population, he said.
"We put them through the same process that we put everyone else through. We make them wait on hold, fight with the reception desk, and sit in the waiting room to spend just a few minutes with the primary care doctor. It is not the kind of care that the person needs. Meanwhile the American public is paying for it."
Because the care is inadequate for the complexity of their health situation, super-utilizers ultimately seek care in the ER, the most expensive care setting.
"A lot of the failures in healthcare are not clinical delivery failures," Brenner said. "They are project management problems. We need much better project management. Healthcare needs to start opening the floodgates and start hiring MBAs from other industries, who would likely shake their heads at what they would see."
One solution Brenner proposes is the uses of health coaches to follow up with high-cost patients and give them more attention, which they require to stay out of the hospital.
"A lot of work can be delegated to someone with different training and lower cost," he said. "Health coaches and navigators can be a part of the team. It makes no sense to take a highly trained nurse or doctor and have them do work that can be delegated to someone else."
Whatever changes ultimately take hold, the healthcare system cannot afford to continue operating as it currently does, said Brenner, who offers a doomsday prediction: "The system is going to collapse because of the long-term federal debt. The system has gotten used to very high annual funding increases, and those are going to slow down."
"But there is no example in the history of mankind of a very large economic system just rolling over. ... It takes a large movement," Brenner added. "If people care about this topic, they need to be part of the solution. This isn't a technological problem; it's a political problem. Patients, providers, concerned citizens, and stakeholders need to stand up and say 'enough is enough.'"
Despite the daily challenges he faces in his work, Brenner said he feels optimistic about the future of healthcare and the possibility of improving care delivery and costs for super-utilizers.
"I do feel hopeful, because if you want to save money, you go where the money is being spent; you go where the people are using the system," he said. "The only way to fix this is to take better care of them. One way or another, the idea of taking better care of really sick people is going to win."