Now and Then: How Intermountain Helps Its Superutilizers

At Intermountain Healthcare’s Dixie Regional Medical Center in St. George, Utah, researchers are genetically sequencing three major cancers to identify patients who will fail an initial course of chemotherapy at a cost of $150,000 to $350,000. Instead, those patients hopscotch to more effective therapies, usually at a cost of $5,000 per month.

“We discovered that on net, there were better patient outcomes and a reduced total cost of care,” says Brent James, MD, Intermountain’s chief quality officer and executive director of the Intermountain Institute for Health Care Delivery Research.

Precision medicine—the genetic cancer sequencing service—is one of many service integration and clinical improvement programs focused on high utilizers of healthcare services that James and a team of researchers are continually developing.

“We’re are at a critical junction in healthcare where we must identify and manage all elements of care,” emphasizes James, whose robust career has focused on quality improvement tools in healthcare.

High Utilizers, Now and Then

Through James’ leadership and Intermountain’s comprehensive analytics division were born two pilot programs based on data analytics: the Comprehensive Care Clinic (CCC) and Community Care Management (CCM). The genesis of both programs began in the mid 2000s, when James was leading a strategic planning committee for a major initiative, Shared Accountability, just as accountable care organizations (ACOs) were coming into fashion.

“We were ahead of the curve,” says James. “Out of those discussions we began to examine the behavior of populations.”

Through healthcare “hotspotting,” James and Harvard MBA Scott Pingree, Intermountain’s Central Region director of strategic planning and chair of hotspotting and high-cost patient care, developed a comprehensive analysis of population health and identified current high utilizers and potential future high utilizers of healthcare.

“Our chief objectives were ‘How can we improve people’s care, is that possible to do, and how can we potentially do it at the lowest appropriate cost?’” explains Pingree.

Pingree determined that the top 5% of high-utilizing patients accounted for 51% of healthcare costs. The top 1% accounted for 24%. A group of roughly 100 patients remained in the top 1% throughout the five-year study period.

As healthcare reform rolls forward and provider incentives move toward fixed payments, these high-cost and high-utilizing patients will become the five-alarm fire for all care providers for one simple reason: There will be no commensurate revenue offset. In the foreseeable future, what was once a profitable or break-even proposition will become a significant financial liability, according to Pingree.

The team mapped out all the care these patients received over a five-year period, including the dates and venues of care. James says they looked for opportunities to improve the continuity of care.

Pingree, who led the analytics study, confirmed it was common for 5% of patients to account for half of expenses within a particular year. But he also discovered that, year over year, consistently high utilizers comprised a much smaller group. Instead, most patients fell into the high-utilizer category for a brief period of time, usually around major acute events.

“That discovery led us to break high utilizers into two categories,” explains James. “One category highlights heavy utilizers, which allows us to analyze ways to step in and make a difference based on patterns of consumption. The second category involves predictive analytics to spot patients who are likely to fail.”

Based on data from the analytics study, Intermountain launched both pilot projects to better coordinate care for high-utilizing patients.

Comprehensive Care Clinic

Intermountain’s CCC provides intensive, team-based care, with staff members spending as much time as needed with every patient. For example, while an internist at a regular clinic may see 25–30 patients daily, a CCC internist may see only six. The CCC team includes professionals from pharmacy, behavioral health and care management. Staff members address issues such as medication reconciliation and compliance, coordination of lab and imaging services, home care needs, transportation, and claims and payment.

For example, pediatric cardiologist Ed Clark, MD, from Intermountain’s Primary Children’s Hospital identified a group of pediatric cases that were “long-term players at massive expense,” such as those on extended ventilator use, notes James.

“Dr. Clark’s team identified a group of 60 complex pediatric patients and built a special clinic that led to a significant decrease in hospitalization,” says James.

Pingree applied the same idea to different settings, including a special clinic that identified continuous long-term high utilizers, usually with significant comorbid chronic diseases, to see if Intermountain could better manage that population in an outpatient setting.

“It’s still early, but the Comprehensive Care Clinic is showing us some pretty good results,” says James.

Community Care Management

Intermountain’s second initiative, CCM, focuses on community resources and provides patients with referrals and coordinated care.

“We identify candidates who might be good patients in the clinic. Then we work with their physicians to see if it makes sense to transfer them over,” says Pingree. “There’s a limited capacity, and they start with a fairly long list. Because it’s a pilot program, it’s been very tightly focused, with 300–400 patients so far.”

Serendipitously, a Primary Children’s physician hospitalist made quite a discovery during her one-year assignment at Intermountain’s satellite pediatric program at one of its community hospitals (Riverton) in the Southwest Valley area of metro Salt Lake City. Near Riverton Hospital is a long-term acute care center (LTAC) that belongs to a third-party, for-profit group and houses very seriously ill children who require institutional care.

Upon arriving at Riverton, the physician hospitalist reviewed patient files and recognized the names of many LTAC children who fairly routinely cycled through Primary Children’s inpatient admissions.

“On her own initiative, she started to help organize the pediatric patients and manage their care in the LTAC,” says James. “When she returned to Primary Children’s, we continued to coordinate services without compromising care to keep those children out of the hospital unless it was absolutely necessary.”

James points out the physician hospitalist’s idea is similar to the CCC. “It’s a less-intense care setting,” he says. “Exacerbations or failings are prevented, and the total cost of care is significantly reduced through better care.”

Pingree says it will take a couple of years to produce solid results for the CCM initiative “to play out all the way, because the consequences are longer-term to measure. However, it looks like a very positive trend associated with a fairly dramatic drop in hospitalization rates.”

Militating Factors

From the viewpoint of a hospital administrator such as Primary Children’s CEO, Katy Welkie, these initiatives could be harmful to the hospital’s fiscal health.

“If you drop admission rates, revenues are hurt, and hospitals have more trouble making financially viable operating margins,” explains James.

Another viewpoint concerns action Utah had taken several years earlier, when the state shifted all Medicaid patients to a Medicaid ACO.

“Come to find out, for most of these kids, Intermountain bore full financial responsibility [through] our health plan, even though they received care at a third-party facility,” explains James. “That meant we were getting a per-member, per-month premium for these children.”

With every admission to the hospital, the hospital made money, but on net Intermountain lost money, says James. “Keep in mind that hospitalization represents treatment failure at some level,” he adds.

To align financials, Intermountain shifted the risk from the health plan to Welkie’s budget at Primary Children’s.

Recently, Intermountain rolled out a special insurance product with a guaranteed low annual rate increase. “We’ve guaranteed them 4% per year for the next three years,” says James, “which is dramatically lower than the inflation rate for typical insurance.”

The only requirement to the product is successfully operating LiveWell, a wellness program Intermountain developed, says James.

Outside the Box

Intermountain has developed a variety of cost-saving programs, such as an extended palliative care model for the elderly.

“We also have chronic disease management. We’re thinking about adding health coaches who try to get patients up to speed in underserved Medicaid populations to better manage their own health,” says James. “It’s based on what Iora Health does in Boston. With predictive analytics, there are so many programs you can run. Probably the best one with the best data, though, is Community Care Management.”

Alongside its own predictive modeling, Intermountain uses Archimedes, a two-version system originally crafted by Kaiser Permanente’s David Eddy, MD, PhD. The Arches version runs at a population level; the Indigo version focuses on a personal level.

“That’s been giving us some pretty good traction,” says James.

The predictive model also provides patients with options. For example, “If you give patients the full picture and a true choice about having some elective surgical procedures, many of them will choose not to go through with the procedure,” he notes. “It’s called ‘shared decision making.’ It originally came out of Dartmouth’s Dr. Jack Wennberg, founder of the Dartmouth Atlas, and Dr. Al Mulley from Massachusetts General Hospital.”

Another focus is full population-level health behavior interventions.

“Partnerships with the local community can significantly reduce the need for health services in general,” James explains. “It’s a move-upstream strategy where you’re trying to get into the ‘healthy behaviors’ layer. It has a long-term tail on it, of course, but if they’re willing to participate, then we’re willing to pass along substantial savings in the form of reduced insurance premiums.

“I think we are at the moment of a great transition,” he adds. “I think a lot of places are really going to struggle with it. I think they’re so deeply addicted to the fee-for-service model, that’s all they think about—it’s all about growth. What if your financial success depended on carefully cutting your revenues instead of growing them? When you get into these waste models, that’s what happens. It’s very counterintuitive.”