Hospitals, Insurers Focus on ED Super-Users To Help Curb Costs
Hospitals and insurers are struggling to lower the number of emergency department "super-utilizers," who were among the 1% of patients responsible for 21% of the nearly $1.3 trillion spent on health care in 2010, Kaiser Health News/Washington Post reports.
Such patients, who might also be commonly known as high-frequency patients or ED "frequent fliers," tend to be individuals with serious chronic conditions, such as heart failure, diabetes, kidney disease or psychiatric problems, according to KHN/Post. Super-utilizers typically fall into one of three categories:
- Medicare beneficiaries who have difficulty affording the medicines they need to control their conditions;
- So-called dual eligibles who qualify for Medicaid and Medicare and tend to shift between EDs for treatment for medical conditions tied to substance misuse or homelessness; or
- Individuals with private insurance.
According to KHN/Post, many ED super-utilizers require emergency care because they face significant struggles in "navigating the increasingly fragmented, complicated and inflexible" health care system.
Hospitals and insurers are becoming more concerned about the problem of ED super-utilizers because of new requirements under the Affordable Care Act that could be costly for the two groups, KHN/Post reports. In 2012, the law began levying penalties annually on hospitals that fail to reduce readmission rates for certain Medicare beneficiaries. Meanwhile, the ACA bans insurers from continuing certain cost-saving practices, such as rejecting applicants with pre-existing conditions or imposing lifetime expenditure caps on health plans.
Many Hospitals, Insurers Already Addressing Problem, With Help From ACA
Several hospitals, health systems and insurers nationwide already have launched initiatives to address the problem of super-utilizers, reduce costs and improve care.
Many of the initiatives are modeled after the Care Transitions program, which was developed by a Denver geriatrician and has been adopted and embraced by CMS for Medicare, according to KHN/Post. The program takes into account a patient's medical and mental health needs, and focuses on social barriers that might trigger unnecessary readmissions.
The ACA also aims to help stakeholders address the problem of super-utilizers, who typically suffer from the phenomenon known as "extreme uncoordinated care," KHN/Post reports. The law encourages health care providers to collaborate and combine their resources to offer coordinated, cost-efficient treatment programs and then share the savings from the effort (Boodman, Kaiser Health News/Washington Post, 10/7).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.