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By Monica E. Oss

Earlier this year, we looked at “superutilizers” – the small percentage of the population that is responsible for the majority of health care spending (see Superutilizers & Mental Illness). Just in the past few months, some very interesting new data has come out on superutilizer care utilization patterns.

The Government Accountability Office (GAO) released an analysis of the distribution of Medicaid spending in May of 2015. Their findings – the most expensive 5% of Medicaid-only enrollees accounted for 48% of Medicaid expenditures (see 5% Of Medicaid-Only Enrollees Account For Nearly Half Of All Medicaid Spending). The least expensive 50% of Medicaid-only enrollees accounted for less than 8% of expenditures. Almost 12% of Medicaid enrollees during each fiscal year had no expenditures over this time period. Of those in the most-expensive 5% of Medicaid-only enrollees, over the three-year period, an average of 51.3% had a mental health condition and 19.19% had a substance abuse disorder. In contrast, among all Medicaid enrollees over the three-year period, an average of 12.8% had a mental health condition and 3.75% had a substance abuse disorder. Of high-expenditure Medicaid-only enrollees in 2011 with co-occurring conditions, 26.73% of enrollees with a mental health condition also had a substance use disorder while 70.83% of Medicaid-only enrollees with a substance abuse disorder also had a mental health condition.

The statistics in a May 2015 report from the Agency for Healthcare Research and Quality (AHRQ), Characteristics of Hospital Stays for Super-Utilizers by Payer, 2012, had similar findings. For superutilizers, the average number of annual hospital stays by payer was four for commercial payers, 4.9 for Medicare, and 5.9 for Medicaid. The report also noted that superutilizers had an average, all-cause 30-day readmission rate about four to eight times higher than the readmission rate for other consumers, and among consumers under 65 years of age, superutilizers accounted for more than half of all 30-day readmissions. Across all payers, the ten most common principle diagnoses for hospitalization among superutilizers include congestive heart failure, septicemia, and pneumonia; schizophrenia and other psychotic disorders, mood disorders, and alcohol-related conditions were among the top 20 diagnoses.

And, a little closer to home (the OPEN MINDS’ main office is located in Gettysburg, Pennsylvania), the Pennsylvania Health Care Cost Containment Council released a report that found that just three percent of consumers accounted for 11% of total admissions and 14% of hospital days (see Pennsylvania’s “Super-Utilizers” Of Inpatient Hospital Care). Pennsylvania had an average of 21.2 superutilizers per 10,000 residents – and the top reasons for those hospitalizations were heart failure, blood infections, and mental health disorders.

The question for policymakers, payers, and provider organizations alike is, how do we manage health care for the superutilizer population? New meta-analysis shows that developing delivery models that align patients’ needs and community assets through partnerships between patients, clinical teams, payers, community, and health care resources is essential. The key is to tie those models to “alternative payment methods; real-time utilization data; easily accessible, state supported health information exchanges; and resource allocation to address social determinants” (see Is A Strategy Focused On Super-Utilizers Equal To The Task Of Health Care System Transformation? Yes.).

What do these new models look like? At The 2015 OPEN MINDS Strategy and Innovation Institute, the Centerstone Research Institute (CRI) team presented one approach that takes these essential elements into account – their coactionHealth Clinical Model. The coactionHealth clinical model integrates mobile health care technologies with data analytics into a care management platform. Their model leverages three primary technologies:

  1. Smart phones – Centerstone has found that the alarm is a simple tool that can really influence health, such as taking medications, checking blood sugar, meeting appointments, and even exercise or drinking water. Also, smart phones assure contact with hard-to-reach populations.
  2. HIPAA‐compliant telemedical services – The use of telehealth services (VideoChat, AudioChat, PhotoChat, and TextChat) provide easy to contact Wellness Coaches and registered nurses, the secure sharing of pictures to provide health information, and the secure communication between staff.
  3. Health monitoring apps – Activity monitors can motivate consumers, encourage healthy eating, ongoing monitoring, and allows for a deeper understanding of clients.

The results from the coactionHealth Indiana pilot were presented by April D. Bragg, Ph.D., Vice President of Research Advancement and Claire R. Bohmann, M.Ed., Coordinator, Center for Clinical Excellence, in the session, Tackling The Superutilizer Challenge With Technology. In the pilot group, the program reduced hospital days by 53%, reduced emergency room days by 39%, and reduced unmet social need by 30% – with an estimated cost savings of over $178,000 (see Centerstone’s Medicaid ‘Super Utilizers’ Hospitalization Prevention Program Reduces Hospital Use).


For many provider organizations, the emerging opportunities in the field are linked to using core organizational competencies to assist health plans and other payers in improving the health status and reducing the resource use of this superutilizer consumer group. The strategic question – what is the model that will deliver the best value for payers and consumers alike? For more, be sure to join the OPEN MINDS team in Washington, D.C. on October 27-28 at The 2015 OPEN MINDS Technology & Informatics Institute for some great sessions focused on the consumer/technology interface including – Community-Based Treatment Through Technology: Remote Monitoring, Wearables & More and How To Make The Right Tech Choices: Adopting New Technologies To Increase Organizational Performance.

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