5% of patients account for 50% of a hospital’s billing. — Stephen Dubner

Growing up an economics junkie, stats like these make me think. Evolving into a policy wonk, it’s abundantly clear that the affordable healthcare act has missed something.

The U.S. spends a larger percentage of its GDP on healthcare than any other country, close to 20%. — Stephen Dubner

If you can address even a portion of those 5% of patients, the savings could be incredible. We’re all paying for it now, whether its through taxes or the private insurance markets, so there is a clear incentive to figure it out.

What’s a Super Utilizer?

These are the patients that show up in an emergency room dozens, or even hundreds of times per year. These are the patients driving up the cost of healthcare.

In a study of super utilizers, researches found one patient that visited an emergency room 450 separate times in a single year. That’s 1.2 times per day funded directly by medicaid.

Hospitals are the most expensive setting for health care delivery, costing between $1,600 and $2,000 a day per patient. — US News

A super utilizer is not necessarily somebody who is terminally ill and needs the hospital repeatedly, but rather it refers to somebody who simply uses the hospital repeatedly. In many cases, this is a result of misuse rather than need. That woman who used the hospital 450 times in a single year was an alcoholic, homeless, and mentally ill, and needed help from a much different kind of institution. Yet, as a medicaid recipient she was incentivized to seek the free care that could not legally refuse her.

In Camden, NJ, which has one of the highest rates of violent crimes in the country, the number one cause for a hospital and emergency room visits over the course of five years was a head cold (12,000 visits). Number two was a viral infection, and number 3 was a sore throat. None of these actually required expensive and sophisticated hospital care, but with a poor population now covered by medicaid the economic incentives compel recipients of this care to continue to use the emergency room.

The famous Washington State study found that accepting somebody into medicaid increased their ER usage by 40%. Keep in mind that hospitals bill medicaid for every single visit, but also tend to be underpaid transferring even more cost onto the required private insurance for the rest of the population.

Nobody is Winning

Patients needlessly returning to the ER over and over is bad for everyone.

• Emergency Rooms/Hospitals: losing money and getting backlogged with patients that don’t really need their help.
• ER Patients: not getting one-on-one attention, not getting better, get prescriptions that they don’t understand.
• The U.S. Government: spending excess money without actually changing behavior and reforming healthcare (helping people be healthier).
• Taxpayers: getting f****d.

Between 2007 and 2011, one study found that 19% of patients were readmitted into the hospital within 30 days. However, for medicare and medicaid patients this number is much higher at 25%. There is a link here.

If the cost of care continues to go up, this cycle will continue to get worse. More people will drop below the poverty line, move to government programs for aid, and increase the cost of care further.

If we can stop super utilizers from returning so frequently we can cut costs.

Changing Behavior: A Pilot

A high percentage of medicare and medicaid patients, specifically, end up returning to hospitals because of their own non-compliance. This shows up frequently within the super-utilizer cohort.

A promising pilot is aiming to provide interventions that will solve this. It’s called Link2Care and it operates out of Camden, NJ. It showed some very promising results. Their approach was rather simple. They created a pool of complicated, challenging cases and then randomly admitted members of that pool into the program. For those who were accepted, they were assigned a medical practitioner who would help guide them following hospital discharge. Setting up appointments, driving them to get their prescription, making sure they were taking their pills, tracking diet, and so on.

Stepping back to politics, this program is very hands on and intrusive. I don’t think the government should be this involved in our lives. But, playing with the hand we’ve been dealt by the supreme court this makes absolute economic sense if it keeps patients from being readmitted into a hospital. It now saves us all money. It also makes people healthier and happier.

While that program was cut short because of funding, there’s another worth mentioning that started operating in Doylestown, PA with a similar mission for medicare patients. Its door to door method reduced net costs by 28% and decreased mortality at the same time by 25%.

Unlike the Camden study, this project has been going on for over ten years and has reached a level of statistical significance. This type of program really works, but the question is how do we scale?

To think it’s simply impossible would be selling ourselves short. Unemployment does exist within the medical field, and we have resources in place to make this happen. Organizing is aided by technology, and what’s missing is the will to do it.

As taxpayers we certainly have an incentive to see something like this through, the hope is that we can be loud enough to give our representatives in government that same incentive.