In some cities, 1 percent of the population accounts for as much as 30 percent of hospital costs. Dr. Jeffrey Brenner, a physician working in one of the poorest cities in the country, Camden, N.J., has attracted a lot of attention for developing programs to provide this small percentage of hospital service “super users” with better, more coordinated care to keep them out of the emergency room and decrease the overall cost to the system.
Now, other locations are starting to emulate the work of the Camden Coalition of Healthcare Providers in focusing on the needs of hospital super-users. Speaking at the State Healthcare IT Connect Summit in Baltimore on April 2, Mike Powell, chief innovation officer of Maryland, said the state spends a lot of money on people who are hospitalized for conditions that could have been prevented. To curb those costs, Powell said Maryland uses data gathered by the state health information exchange and GIS tools from ESRI to help health system, Medicaid and public health officials identify trends and better target their limited resources. One effort involves the creation of five Health Enterprise Zones funded with $4 million in state general funds. As part of the plan, the Anne Arundel Health System established a patient-centered medical home -- staffed by a physician and medical assistants -- in an underserved area of downtown Annapolis with high rates of emergency room utilization, hospital admissions and re-admissions, and a large volume of medical 911 calls. Under a Medicare waiver, the state of Maryland also is using a new model to reimburse providers based on the health of populations rather than the amount of services they provide. That has led to a hunger for data about patient populations and hospital re-admissions. “A few years ago we set a goal of lowering readmissions by 15 percent by 2015,” Powell said, “and we are already around 11 or 12 percent of that.” He added that the target would likely be reset looking ahead to 2020. Noting that Maryland just added 235,000 people to its Medicaid rolls, Powell said the state has to do a better job of keeping people healthy. “The more information you have about patients, the better able you are to measure results,” Powell said. The statewide health information exchange, the Chesapeake Regional Information System for our Patients (CRISP), is central to that data gathering and sharing. The consortium of hospitals made Maryland the first state to have all acute-care hospitals sharing data on admissions and readmissions with one another. “We have a better picture of health than when everyone was in a silo,” Powell said. “This information collected by hospitals is one of the fundamental things we need to achieve our goals.” Scott Afzal, CRISP's director of statewide health information exchange, said getting hospitals accurate information about readmissions anywhere in the state is a major step. Hospitals are being penalized for readmissions no matter where they occur, and previously there was no way to know if your patients were being admitted elsewhere, he explained. Beyond inter-hospital readmission reports, CRISP is moving on to “hot spotting” super-users by specific location -- an effort that's growing out of Brenner’s work in New Jersey. The state data shows that 5 percent of patients represent 70 percent of readmissions. Now Maryland is working with 24 local health departments to identify innovative approaches to treating these super-users. But Afzal admitted there are privacy and security concerns around mapping health data and who gets access to the maps. If a patient lives in what is defined as a hospital’s primary service area but gets all his care across the state, is the local hospital allowed to see that data? Can data provide valuable geographic information to public health providers while protecting the privacy of individual patients? These are questions that policymakers will have to address, Afzal said. Kentucky also is targeting super-users. Speaking at the same Baltimore summit meeting, Dr. John Langefeld, chief medical officer for the Kentucky Department of Medicaid, noted that Medicaid is historically the largest payer in the state, with approximately 25 percent of the state's population eligible for the program. He said Gov. Steve Beshear asked Langefeld's organization to focus on super-utilization of emergency rooms. Research indicated that among patients who visited the emergency room 10 or more times in a 12-month period, 79 percent had behavioral health issues, and 45 percent had a substance abuse diagnosis. So obviously behavioral health providers have to be part of the solution. Langefeld said the Cabinet for Health and Family Services is using the state HIE to deliver alerts to hospitals and newly forming care coordination teams. The state also is working to improve data sharing among its many program areas. In both Maryland and Kentucky, state health information exchanges are playing a critical role in getting data to providers who are seeking more effective ways to care for patients with chronic conditions.