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January 10, 2020

Our take: A new study casts doubt on 'hotspotting'—but don't abandon your program just yet

Daily Briefing

    A program designed to reduce health care spending and improve health care quality among so-called "super-utilizers" did not result in lower hospital costs or fewer readmissions, according to a rigorous study published Thursday in the New England Journal of Medicine.

    Your guide to implementing a successful super-utilizer program

    Providers look to crack the code on so-called 'super-utilizers'

    Super-utilizers are patients with serious illnesses who frequently visit the hospital and ED. They tend to be uninsured or enrolled in Medicare or Medicaid. Super-utilizers account for just 5% of the U.S. population but 50% of health care spending, the Associated Press reports.

    Providers have been working to identify super-utilizers and address the root causes of their health problems in an effort to curb health care spending—a practice referred to as "hotspotting." For example, the Camden Coalition of Healthcare Providers 10 years ago launched a care-transition program aimed at reducing readmission rates and hospital costs among super-utilizers by providing the patients, who typically are very sick, with continued access to care and other resources after they are discharged from the hospital. Under the program, a team of community health workers, nurses, and social workers visited the homes of super-utilizers to coordinate their outpatient care and connect them with social services.

    Early research suggested the program succeeded at reducing readmissions among super-utilizers, and the program gained national attention. Though the evidence demonstrating the program's initial success was weak, according to the New York Times' "The Upshot," the federal government lent support to further evaluate and expand the initiative, and the effort sparked similar programs throughout the United States.

    New study shows program didn't reduce readmissions

    Researchers set out to further evaluate the program's effectiveness and randomly assigned 800 patients who were hospitalized at least twice during a six-month period, had two long-term health conditions, and had at least two other circumstances complicating their lives—including homelessness, a mental health condition, drug misuse, difficulties accessing services, use of five or more medications, or no social support—into two groups after they were discharged. One group participated in the care-transition program for three months, which cost about $5,000 per patient. The other group received usual care, according to AP.

    The patients in the care-transition program on average received 7.6 home visits and 8.8 phone calls from program staff during the three months following their hospital stay. In addition, the program's staff accompanied patients to an average of 2.5 visits with their physicians.

    The researchers evaluated the outcomes of both patient groups six months after the patients' were discharged from the hospital and found similar results for each group. Overall, the researchers found patients in both groups had nearly the same chance of returning to the hospital and the same number of readmissions, spent nearly the same amount of time in the hospital overall, and generated nearly the same hospital costs.

    Specifically, the researchers found both groups had a readmission rate of 62%, and there was no difference in total health care spending between the groups. The researchers also found that two of the program's key goals—providing patients with a home visit and ensuring patients visited a provider within one week of leaving the hospital—were achieved for just 28% of patients in enrolled in the program.

    Why didn't patients enrolled in the program have better outcomes?

    The researchers noted a few reasons why the program might have failed to show significant improvements when compared with the control group. For example, the researchers said usual care provided to patients in the control group might have improved. They also said homelessness and lack of access to a telephone among patients enrolled in the program might have inhibited its effectiveness.

    In addition, the study might not have used a large enough sample size, which could have affected the results. It is possible outcomes varied across groups in small ways that could not be detected by the study's small sample size, "The Upshot" reports.

    Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers, said the three-month evaluation period also might not have given the program enough time to help patients. She also noted there weren't enough places to help patients access care for substance use disorders or mental health conditions.

    Jeffrey Brenner, a founder of the Camden Coalition of Healthcare Providers who now works on similar programs for UnitedHealthcare, said, "The bottom line is, we built a brilliant intervention to navigate people to nowhere." He continued, "The system is good at delivering care if you're an average patient on an average day," but "[t]hese patients have complex problems. If you don't meet their needs, they'll keep going to the hospital." (Daily Briefing is published by Advisory Board, a division of Optum, which is a wholly owned subsidiary of UnitedHealth Group. UnitedHealth Group separately owns UnitedHealthcare.)

    Aaron Kesselheim, a health policy expert at Harvard Medical School who did not participate in the study, said the program was "clearly done with the best of intentions" and might have benefitted patients without reducing readmissions. Overall, Kesselheim said reducing readmission rates appears much more complicated than it might have seemed (Frakt, "The Upshot," New York Times, 1/8; AP/NBC News, 1/8; Finkelstein, New England Journal of Medicine, 1/9; Gorenstein/Walker, "Shots," Kaiser Health News/NPR, 1/8; Emery, Reuters, 1/8).

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