A way to save money when half of all health costs is spent on a fraction of patients

Health care “super-utilizers” make up just 5 percent of the U.S. population but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to figure out how to find these patients and get to the root of their problems. But the looming repeal of the Affordable Care Act may disrupt those efforts. Special correspondent Sarah Varney reports.

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    But first: how some lesser-known changes to health care might fare, given president-elect Trump's vow to repeal the Affordable Care Act.

    One of those involve so-called "super utilizers" — high-cost patients who frequently turn to emergency rooms for problems better handled by primary care doctors and social workers.

    Special correspondent Sarah Varney reports.

    This story was produced in collaboration with our partner Kaiser Health News.


    Protective gown. Rubber gloves. Face mask. Dayna Gurley is getting dressed for work. She's a social worker charged not with treating infectious diseases, but with figuring out why her clients all but live in Houston's hospitals.

  • DAYNA GURLEY, Social Worker:

    What's been going on?


    This patient, who asked not to be identified, has chronic massive ulcers, AIDS, hears voices, and, at times, spends three weeks out of the month at multiple hospitals around Houston.

    Gurley is part of a promising effort in the U.S. health care system: Honing in on so-called "super-utilizers," patients with complex problems who frequent emergency rooms and cost public and private insurers dearly.

    Super-utilizers make up just 5 percent of the U.S. population, but they account for 50 percent of health care spending. As health care costs continue to rise, providers are trying to find these patients and get to the root of their problems.

    An effort to do just that started in New Jersey's poorest city: Camden. Family physician Dr. Jeffrey Brenner was inspired by how police departments were using crime data to detect hot spots. To find Camden's health care hot spots, Brenner dug into ambulance records and E.R. data to show how high-cost patients were shuttling between city hospitals.

    DR. JEFFREY BRENNER, Camden Coalition of Healthcare Providers: In America, we're medicalizing social problems, and we're criminalizing social problems, and we're wasting huge amounts of public resources.


    To steer super-utilizers away from expensive emergency care, Brenner's team, including social workers Latonya Oliver and Bill Nice, seek patients out in local neighborhoods.


    There's been a few patients that I have had like that…


    They work intensively with people like Peter Bowser.

    Bowser was once homeless, and went to the E.R. 28 times in one year.


    Because I was telling people when I was staying in the shelter, I said, 'When I get my place,' I said, 'I'm going to maintain it.'


    But after they helped get a permanent roof over his head, Bowser's trips to the E.R. all but stopped.


    And I think you would prefer to spend your time here than the hospital any day of the week…


    This high-touch, data-driven approach has yielded big savings. E.R. visits for the first group of patients dropped by 40 percent, cutting monthly hospital bills from $1.2 million to $500,000.

    The Affordable Care Act has boosted efforts like this around the country by funding so-called Accountable Care Organizations — teams of health care professionals who team up to improve care, lower costs and reap the savings.

    And it was Brenner's pioneering work in Camden that inspired others, including the program in Houston — a sprawling city desperate to aid its sickest and most isolated patients.

    While the more than 100 hospitals here typically know their own super-utilizers, they had no way of knowing the top users across the entire city. Tackling that problem took unprecedented planning among typically disjointed city and county agencies, hospitals and nonprofits.


    And you know that guy that you helped me get appointments for the other day? He apparently had warrants out for his arrest.

  • WOMAN:

    Oh, OK.


    Now, many of the hospitals here, including the county hospital, Ben Taub, pool their data and send it to Kallol Mahata, a former oil industry I.T. engineer with the Patient Care Intervention Center, who combines it into one database.


    And we saw that breakdown by EMS.


    Mahata and Dr. David Buck, the group's founder, help to identify patients at the top of the list — the outliers of the outliers. Some of the data comes from the Houston Fire Department's 911 calls. Then, teams are dispatched to parks and neighborhoods to find the patients.

    Firefighters and paramedics like Thomas Pierrel often know these residents from those emergency calls. But, this time, their mission is different.


    We make appointments. We find specialists. We try to maximize the resources that you have.


    The results of these intensive interventions can be stunning. Timmy Williams was dying when Dayna Gurley found him.

  • WOMAN:

    Has your blood pressure been that high in the past three or four weeks?

  • TIMMY WILLIAMS, Houston Resident:


  • WOMAN:

    It has been?


    Yes, it be high. It be up there.


    He was holed up at home and reeling from untreated HIV that had progressed to AIDS. He couldn't take care of his young son, and cycled through Houston's hospitals.


    When we first met Timmy, he was very hard to engage. We knew that he probably wasn't taking any of his medication, and he was very skinny.


    Gurley arranged for a home aide to care for Williams seven days a week, got his apartment cleaned and the lights turned back on. Now, Williams' HIV is undetectable and his health, and life, have been steadied.

    Although these efforts involve many staff members, in the two years since the Patient Care Intervention Center has been up and running, costs for those in the program have gone down 83 percent and hospital visits by 70 percent.


    I really want to get to know them and spend time with them…


    But it can be difficult to keep these programs moving. Often, those savings go straight to insurance companies and government payers. And Dr. Buck and Dayna Gurley were once banned from a Houston hospital that was afraid of losing money if their high-cost patients stopped showing up.

  • DR. DAVID BUCK, Patient Care Intervention Center:

    Nobody wants to take ownership of any of it. The people just want ownership of what they have authority over. And that's really the issue.


    Back in Camden, even Dr. Brenner is less optimistic than he once was. His office now overflows with pillows and kitchenware for clients they're trying to place in housing, and he thinks homelessness and entrenched financial interests in health care are the biggest barriers.


    I think this is going to take a lot longer than I ever imagined. I think we're in a 20-year arc of recalibrating and rethinking what is health and what is health care, what is the purpose of our health care system, what are we trying to accomplish?


    But Brenner still believes these intensive efforts are the best way to help patients like Timmy Williams. He's now healthy enough to make his way around the city on his own. He says Gurley did more than rescue him from his darkest days.


    I had to put it in my head that no one is going to do it for me. I have to do it for myself. I have got to step out and do it myself.

    Read this here.


    This whole thing?




    At home now with his son, his illness no longer gets in the way of being the father he wants to be. But efforts like these could be undercut if president-elect Donald Trump and the Republican Congress follow through on their vow to repeal the Affordable Care Act. And it's unclear what would come next.

    For the PBS NewsHour and Kaiser Health News, I'm Sarah Varney in Houston, Texas.

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