The American medical system is good at providing care to people in the middle: those who need regular doctors’ visits and a few medications. But the system is inadequate for many patients with complex needs. And although they make up a tiny proportion of healthcare users, these high-need patients end up using a shockingly high percentage of health dollars.
An approach called “hotspotting” is one answer. It uses data and relationship-building to identify the super-utilizers and target them with integrated and holistic support that goes well beyond the clinic. Host Frank Stasio talks with Mark Humowiecki, director of the National Center for Complex Health and Social Needs at the Camden Coalition of Healthcare Providers, about the history of hotspotting and the cost-benefit analysis that underpins it.
He also speaks with Dr. Amy Weil, faculty advisor for a student hotspotting program at the University of North Carolina Chapel Hill, about how this approach plays out for providers and patients. And he speaks with Madhu Vulimiri, a public policy graduate student at Duke University’s Sanford School, about the challenges of instituting hotspotting and the policies necessary to do so in our state.
Mark on how hotspotting got started:
More than 10 years ago a primary care doctor named Dr. Jeffrey Brenner was organizing a group of fellow primary care providers, and they [realized] … That a small number of patients, many of whom they knew and treated, accounted for a disproportionate amount of cost. One percent was responsible for almost 30 percent of charges. Five percent: half the costs of all health care in Camden. And they realized that a lot of these costs were preventable ... A lot of patients' frequent utilization of the hospital was driven by a complex array of factors that included disease – physical disease but also mental illness – often problems with substance use, social issues. A lot of folks are homeless or have very unstable housing situations or are socially isolated. And these factors can combine to drive patterns of frequent utilization that have a lot of cost for the system and that don't generate very good outcomes for the individual patient.
Madhu on the cost savings possible through hotspotting:
We've seen, obviously, models like Camden Coalition be really successful. We've also seen some states start to do pilots of hotspotting within, say, a particular region of the state or with a particular sub-population, such as substance abuse or mental health patients. And these programs generally have been shown to really make a dent in reducing emergency department visits, reducing some of those unnecessary hospitalizations. And then finally what we're hoping for, which is decreasing long-term costs for, say, the Medicaid program … Medicaid is really, in North Carolina, at an inflection point where we are about to move into a new system of how we pay for care and how we pay providers. And at the same time it's an opportunity for us to think about how we can redesign care to better meet the needs of Medicaid patients. So hotspotting featured pretty prominently as a strategy that we recommended to state policymakers because of its success in not only Medicaid but other patient populations.
Amy on a patient students in her hotspotting program assisted:
Students advocated for a person who had wounds that needed closing. And he was going back and forth to nursing homes and the hospital and was about to lose his apartment. He had been paraplegic and probably was perceived to be, as an advocate for himself, a somewhat difficult patient. And the students really got to know him and understood that his goal was to be independent and work and stay in his apartment. And they managed to be an advocate for him. And between the nursing home and the surgeons he had his surgical procedure done, and he's back in his apartment, and he's a regular patient now ... Short term: expensive. Long-term: back to regular person.