Penn. Finds `Superutilizers` Account for Disproportionate Claims Payments

March 02--Pennsylvanians who are more frequently admitted to the hospital claim a disproportionate amount of public health money, according to a recent study by a state health cost-tracking agency.

Research published in February by the Pennsylvania Health Care Cost Containment Council, or PHC4, shows patients admitted into a hospital five times or more between July 2013 and June 2014 comprised only 3 percent of total inpatient admissions.

But those 3 percent ate up 14 percent -- or $545 million -- of all inpatient Medicare claims payments and 17 percent -- or $216 million -- of all inpatient Medicaid claims payments.

It comes down to access.

Patients who lack health insurance or a primary care physician, especially those with chronic illnesses like diabetes, heart disease or chronic obstructive pulmonary disease, often don't get regular care to effectively manage their symptoms.

Richard Martin, M.D., department director for Geisigner's community practices in Lackawanna and Monroe counties, said it's a lack of regular maintenance that leads to catastrophe in the form of emergency room visits, followed by longer stays in the hospital.

"Many of these people just don't have insurance," he said. "So they wait until an illness becomes more significant that they end up in the emergency department."

Experts blame a flawed health care system, saying the burden, at least in part, falls on doctors to offer preventive and follow-up care patients need to stay out of the hospital bed and a few steps ahead of their illnesses.

While it may seem these so-called "superutilizers" are taking more than their fair share of public health resources, many health care professionals in the region are quick to caution against throwing accusations.

"I don't think it would be fair to say, 'well, these people are abusing the system; these people are feeding at the trough inappropriately,'" said Justin Matus, Ph.D., associate dean at Wilkes University's Sidhu School of Business.

Reducing the number of superutilizers not only saves tax dollars, but it also brings better health for patients and the community, according to Karen Arscott, D.O., associate professor at The Commonwealth Medical College.

"The financial part of it, I don't want to minimize it," she said. "But that really is a small part of it. There are so many other things that are impacted by one person's health challenges."

Her colleague, Janet Townsend, M.D., chairwoman of TCMC's Family, Community and Rural Health Department, agreed.

"And if you were to look at them as a group, they have shorter lifespans and have increased suffering in many dimensions, no matter how you measure it," she said.

Northeast Rates Better

Statewide, superutilizers spent nearly six days in the hospital per stay compared to 4.4 days for those admitted one to two times in the same studied time frame, the PHC4 said.

Heart disease, infection and lung disease were most common among superutilizers in the northeast counties of Lackawanna, Luzerne Monroe, Pike, Susquehanna, Wayne and Wyoming. Statewide, the most common three reasons for the same group were heart failure, infection and mental health disorders.

Although mental health disorders didn't make the list for northeast counties (with the exception of Monroe County), Dr. Townsend said other data shows mental health disorders still are quite prevalent in the region.

Research shows the northeast region is swamped with smokers, so it could be that lung disease simply dwarfs the mental health issue, she said.

County by county, Northeast Pennsylvania had fewer than the statewide average of 21.2 superutilizers per 10,000 residents, with 19.1 in Lackawanna County; 17.3 in Luzerne County; 15.7 in Monroe County; and the state's lowest ratio, 6.6 per 10,000 residents, in Pike County.

Wyoming County came in slightly above average with 23 superutilizers per 10,000 residents.

Experts speculated why the northeast rates better, but agreed it doesn't mean the region is without serious health problems.

Dr. Townsend referenced annual studies compiled by the University of Wisconsin Population Health Institute, that show Luzerne, Wyoming and Susquehanna counties rank near last for overall health conditions.

Curbing Readmission

Both Commonwealth Health and Geisinger hospital networks have confronted the superutilizer problem head-on in the last several years and are developing programs to keep folks out of the hospital.

More and more hospitals are pushing at-home recovery and outpatient care for several reasons, said Tina George, M.D., a Commonwealth Health family doctor in Avoca.

For one, patients recovering at home are away from other patients who may be carrying germs. But there's also a major cost incentive to preventing frequent fliers.

"Hospitals have been super-aggressive about trying to curb readmissions," Dr. George said. "For certain diagnoses, (Centers for Medicare & Medicaid Services) will not pay for readmission if there's a readmission within 30 days."

Commonwealth Health uses outpatient care managers to help patients learn about medication, to monitor their recovery after surgery or serious illness and to manage their chronic symptoms, Dr. George said.

Commonwealth also is putting an emphasis on palliative care, which uses medical teams to help patients with chronic illnesses like diabetes and heart or lung disease.

Geisinger uses its ProvenHealth Navigator program to connect patients with case managers who, depending on illness severity, may communicate on a daily basis.

Dr. Martin said between 15 and 20 percent of Medicare patients end up requiring a navigator, but Geisinger has found those in the program spend less.

"We've actually shown that the people in this program have a 7 percent decrease in their overall cost of care, and that's been consistent in the six years that we've been running this program," Dr. Martin said. "This is not about denying people to the hospital. It's about keeping them healthier so they don't have to go to the hospital."

Contact the writer: joconnell@timesshamrock.com, @jon_oc on Twitter

Copyright 2015 - The Times-Tribune, Scranton, Pa.