Three percent of patients hospitalized in Pennsylvania in fiscal 2014 were "super-utilizers" - people admitted five or more times in a year, according to a new report from the Pennsylvania Health Care Cost Containment Council.
Those 21,308 people accounted for 11 percent of total admissions and 14 percent of hospital days. The report estimated that super-utilizers were responsible for $545 million - 14 percent - of Medicare payments for inpatient stays and $216 million - 17 percent - of Medicaid payments in 2012.
While the report made no attempt to gauge how many of those hospitalizations could have been prevented with better outpatient care, the assumption is that some could have been, said Joe Martin, executive director of the agency, known as PHC4.
The idea that a small subset of patients drives a disproportionate amount of cost is a "hot topic," Martin said. He said he hoped the data would help inform efforts to improve care. "It can further the dialogue and action about how to make sure patients get the right care at the right time in the right setting so that quality and cost-efficiencies are maximized," he wrote via e-mail.
Insurers have been changing how they pay health providers to reward them for keeping people healthy. They also have begun to penalize hospitals when patients are readmitted too soon. As a result, many hospitals are trying to prevent readmissions.
Martin said he did not know if those efforts had reduced the number of super-utilizers.
Statewide, the top reasons that super-utilizers were hospitalized were heart failure, blood infections, and mental-health disorders. The groups most likely to need frequent hospitalizations were people 75 and older, blacks, and residents of poor neighborhoods.
Pennsylvania had an average of 21.2 super-utilizers per 10,000 residents. Philadelphia had the state's highest rate, 33.2 per 10,000. Suburban counties had half to two-thirds of Philadelphia's rate.
Michael Consuelos, senior vice president of clinical integration for the Hospital and Healthsystem Association of Pennsylvania, a hospital trade group, said the report was "no surprise for us folks who work in the quality improvement arena."
He said super-utilizers were often people with complex needs and limited access to primary and specialty care. The degree to which behavioral health was a factor was one of the more striking aspects of the report, he said. That illustrated the need to address the "social determinants of health" - issues like poverty - and better coordination of mental and physical care.
Consuelos said some health systems were experimenting with putting mental-health and medical providers in the same office.
He said he wanted to see how the super-utilizer statistics changed over time. This first report, he said, "lays the groundwork for us to shift our focus from volume to value."
Barry Jacobs, a psychologist involved with Crozer-Keystone Health System's efforts to reduce overutilization, said people with serious mental illnesses often smoke and may have medical problems related to their medications. The psychological problems may reduce their ability to manage their medical illnesses.
The system is currently focusing on frail elderly patients with two admissions within six months or three emergency-room visits in a year. Its small program, funded by Independence Blue Cross, appeared to reduce admissions 30 percent last year. It is now expanding.
In this population, improving care may involve helping patients afford their medicine or live in safer housing, Jacobs said.
"These patients are not being well served by the health system," said William Warning, program director of the Crozer-Keystone family medicine residency program, home of the super-utilizer programs.
There were 21.2 "super-utilizers" - patients admitted to the hospital five or more times a year - for every 10,000 Pennsylvania residents in 2014.
The rate varies widely by county, perhaps due to age, race, and poverty:
Bucks . . . 18.2
Chester . . . 15.3
Delaware . . . 22.2
Montgomery . . . 15.7
Philadelphia . . . 33.2
SOURCE: Pennsylvania Health Care Cost Containment Council (www.phc4.org)EndText