Read Advisory Board's take: The lesson this program can teach providers.
Maryland's state-funded Health Enterprise Zones led to 18,562 fewer inpatient stays and a net savings of $108 million over four years, according to a recent Health Affairs study.
About Maryland's state-funded program
In 2013, Maryland launched the Health Enterprise Zone Initiative to improve access to care and care coordination in five of the state's geographic regions with poverty indicators such as below average life expectancy and high rates of Medicaid use. The program aims to attract primary care providers to these communities as well as reduce ED visits, health care costs, and hospital admissions, while improving health care access and promoting healthy behaviors.
Each of the five regions received resources to attract and retain primary care physicians and other health care professionals to offer health care services in the medically underserved communities. These health care services were intended to specifically target chronic conditions, including asthma, behavioral health problems, cardiovascular illnesses, and diabetes. They also provided access to social services, behavioral health services, dental care, and health education.
To analyze the impact of the program, researchers from Johns Hopkins Bloomberg School of Public Health examined state data on ED visits, hospital inpatient admissions, and health care costs from 2013 to 2016. The researchers compared the metrics in the 16 zip codes included in the program with 94 zip codes with similar demographics.
Over four years, the researchers found the state spent $15 million on the program, which generated about $108.5 million in net savings during that timeframe. The researchers found the program had been associated with 18,562 fewer inpatient stays, which generated $168.4 million in savings. These declines were greatest for stays associated with chronic conditions, including diabetes, chronic obstructive pulmonary disorder, and hypertension.
However, the researchers found the program was also associated with 40,488 additional ED visits, which cost $60 million. Researchers explained the additional ED visits do not necessarily indicate that a higher number of ED physicians were seeing patients. Rather, Darrell Gaskin, director of the Hopkins Center for Health Disparities Solutions at the Bloomberg School, said, "Some of this is emergency physicians not admitting patients, which they normally would have done, because now they're comfortable with sending those patients home."
Gaskin said, "Now they know the patient has a care coordinator or primary care provider in the community who they can immediately connect that patient with to help them manage their care. So, what we would have seen in our data as an inpatient stay, instead we see an ED visit."
The study's authors concluded that the program indicates that providing incentives for health care providers to go to underserved communities can have large implications on hospital utilization and can generate a strong ROI. As Gaskin concluded, "We see a large cost saving here from a relatively small investment." (Commins, HealthLeaders Media, 10/3; Abraham, Healthcare Dive, 10/3; Gaskin, Health Affairs, October 2018).
Advisory Board's take
Tomi Ogundimu, Practice Manager, Population Health Advisor
What resonated most to me in this study was how each zone's program was tailored to meet the unique needs of their community.
As part of the Health Enterprise Zone (HEZ) initiative, each zone received resources and incentives targeted at community health improvement, enhanced primary care services, hiring new staff and addressing the social determinants of health. However, it was up to them to decide how to use these resources and which programs to create. Therefore, some zones focused on opening new ambulatory health sites to provide mental health and dental care, while others focused on healthy food programs or school-based services.
This customized approach reflects a best practice we've uncovered in our own research: Prioritizing community health interventions by using a data-focused approach to carefully assess the community.
The reason for this approach is simple. Providers who look upstream and try to improve population health often end up with a long list of possible options to pursue—and they often feel overwhelmed and paralyzed by all the choices.
“This customized approach reflects a best practice we've uncovered in our own research”
That's why it's essential for providers to first define a set of measures that capture the organization's targeted health priorities. For instance, while almost all care transformation initiatives focus on outcomes related to reduced inpatient utilization, readmissions and ED visits, individual communities often have their own localized needs, such as chronic conditions management, behavioral health, or maternal and infant health. Providers can identify these unique needs by conducting a community needs assessment, looking at open-access data sets or speaking with community members and patients.
Zoning in on these unique 'hot spots of need' allows providers to truly identify the areas likely to return the greatest dividends for their investment. However, providers will still typically end up with a list of 10 to 12 priorities—too many to address at the same time. Therefore, population health managers will need to further prioritize the list of challenges by comparing size of the improvement opportunity with the availability of resources to address those needs. By carefully considering how much investment will truly be required for each opportunity—and what resources will be necessary to put it in place—the best opportunities should naturally rise to the top.
To learn more about how to prioritize population health interventions—and to get the tools to help—be sure to download our 10 Tools for Prioritizing Community Health Interventions.
Then, once you've identified the best opportunities, discover the best practices we've found around implementing those opportunities with the 3 Imperatives for Investing in Successful Community Partnerships.