Podcast Episode Transcript: Super utilizers: A breakthrough approach to care management

With L. Gordon Moore, MD

Gordon Moore: Welcome to the 3M Inside Angle podcast. This is your host Dr. Gordon Moore, and with me today is Dr. Jason Greenspan. He is a emergency medicine physician and the associate chief medical officer practicing with Emergent Medical Associates. Welcome, Dr. Greenspan.

Jason Greenspan: It’s nice to be here. Thank you.

Gordon: I saw an article that you had in Becker’s Hospital Review, back in August, talking about identifying and addressing the underlying causes behind high ED utilization of patients, and I was really interested in that. So that’s where I want to go, but just give me a little thumbnail of who you are, where you’re coming from in writing this article.

Jason: Yeah. Sure. So, at my core, other than being a father and a husband, I’m an ER doctor. I’ve been practicing in the San Fernando Valley, the northern part of Los Angeles County, for about 20 years since graduating USC for my training. I have been practicing and developing as an ER leader and ER director over that time. And so, fundamentally, I consider myself a bedside doc who’s seeing patients and trying to take good care of them, and that as an ER director trying to work with the systems that I’ve got in those hospitals, in those ERs, to make it better for all the care that we’re providing and all the care that the doctors are providing, etc., which is how we got to this project with the high utilizers.

Gordon: Tell me about that. Obviously, as an ER doc, you’re working with all sorts of people. You see high-utilized as the people who are coming in all the time. Why was that an issue to you and what triggered this?

Jason:  I think every ER doctor knows what it’s like to see that “frequent flyer” come through the door again, for them to show up on your tracker board, or for you to pick up the next chart, and just say, “Oh, it’s her again” or “him again. Didn’t I just do this yesterday, or last week, or a month ago, or something like that.” And, in all honesty, it started, maybe, from a place of frustration.

It seemed like an awful lot of what I was doing in the emergency department, both as a doctor and as a director, was managing people that never really seem to get out of what seemed like a rut. They were just back in the emergency department again, and again, and again, and that was sometimes for their asthma, or their COPD, or their CHF, and oftentimes for their mental health issues, and oftentimes for their substance-abuse issues, and even, maybe, more so a combination of all the above. And it was just ultimately very frustrating.

As a physician, you always want to feel like you’re making a difference and you’re helping people getting better or, at least, down a path towards something that makes more sense and makes them healthier, and this patient population just was the opposite of that. It felt like an awful lot of work and an awful lot of resources was being put into taking care of this group of people that never got down the path, never got healthier, and just kept starting from the starting point again. Like I said, that was just really frustrating.

We heard about some ways to manage the population and how people starting tracking the population through ACEP and through ACEP’s work in Washington State. And I still remember, myself and my partner, we had a conversation one day that was just along the lines of “Wow, check this out. They’re following these people, and they’re managing them, and wouldn’t that be cool if we could kind of do the same thing.” That’s how it all just got started is that we wanted to get out from a place of frustration towards a place of, at least, trying to do something about it that if it wasn’t able to fix the problem, at least, it was getting us started towards fixing it.

Gordon: And for those who may not know, what’s ACEP?

Jason: The American College of Emergency Physicians. So that’s the ER physicians’ national college.

Gordon: And, in this college, you were hearing about work that others were doing, and you thought that was interesting?

Jason: Yes. So the American College of Emergency Physicians, or ACEP, A-C-E-P, through various different ways, shares best practices across ERs and across the practice, internationally, but certainly in the United States. And so through various publications that they have, and podcasts, etc., as well as just kind of local discussions and conferences, you hear about these programs, and this was one of them.

Gordon: Something caught your ear, and you thought “We should try that here.”

Jason: Exactly. The initial information that we got from up in Seattle and Washington was that they had put a program together regionally that was reviewing their high utilizers not only in one ER but across a geography, which was really interesting. Because we knew that for all the frustrations of these people showing up to one ER, they were showing up to multiple ERs, and at the time, we were working really in a silo of one ER at a time.

Our organization services a number of ERs in the geography of the San Fernando Valley where I practice. And so, myself, for example, as the regional director, in the San Fernando Valley, I would go from hospital to hospital and ER to ER working clinically and administratively. I would see things like, “Oh, I just saw that patient at the hospital down the street the other day,” and then you would see them at a third hospital or a fourth hospital.

And so that frustration that I expressed before about what was it like to see that person over and over again at a single hospital, now all of a sudden got multiplied by two sites, or three sites, or multiple hospitals across the geography. And what we heard about, what was going on in Seattle, was that they were noticing a very similar thing, and they were linking together their emergency departments in a way that shared information, specifically, about this patient population, and that allowed them to shed some light on who these patients are, allowed that information, then, to get into the hands of the ER doctors that were seeing that person in the emergency department in real time. And then, on the back end, it was allowing them to case manage these patients in a way that hopefully got them off of this gerbil wheel and out of this cycle of recurrently being in ER, and instead, hopefully, like I said before, managing them towards a path of actually getting better.

Gordon: So it sounds like at first you had a unique opportunity because you’re crossing over different ERs, and you see “Okay. this person, I just saw the other day. This is an issue. That seems wrong. There’s something going on here that we’re not addressing.” Then, you hear about the data linking. And so tell me more about that. How does that work? You’re all on the same EMR? Is that how it works?

Jason: No. So, in fact, the beauty of the program was that, at the time, none of us were on the same EMR, so we have a group of hospitals that had a combination of Epic, and Cerner, and MEDITECH. We were on as many EMRs as I can imagine there are out there, and none of them were speaking to each other. And that’s a frustration to begin with. One of the things that originally caught our eye about this program was that it was one of the first things that bridged the various EMRs.

Now, all of a sudden, even though I wasn’t getting full access to the EMR outside of my own ER into the next one down the street, I was getting a clinical snapshot of that patient that was presenting, even from the hospital down the street. Now, all of a sudden, I could see patterns from these individuals, right? So a typical case was somebody with a mental health issue and a substance-abuse issue, concurrently, and I had just taken care of them at hospital A and had deescalated them, or sobered them up, or whatever it was, and had been able to discharge them home with some semblance of a discharge plan.

And then they would show up, maybe, three of four days later, for example, at hospital B. At the time, if I was now the ER doctor at hospital B, I couldn’t see what I had just done at hospital A. This was one of the first programs that, then, broke that down, and all of a sudden, it was very clear to us in the ER, at the beginning of the patient encounter, that this patient had just been through this. We had just done those labs. We had just done that CAT scan. We had just given that medication. And initially it allowed us to really improve just operationally, but then again ultimately started allowing us to see patterns with these patients to try to case manage in a better way.

Gordon: Yeah. I’m curious now. So data, obviously, is key. So you were able to, then, work with a system that breaks through the data barriers that frustrate us all when we know the same people are taking care of the same people, and we can get the information. So you get that solved. But then I’m curious also about the patterns. Is it just there’s a diagnosis that’s undertreated or is it more complicated than that?

Jason: I would say that, at some times, it was diagnosis that was not treated, but I would say that was the exception and not the rule. So rarely would it be that all of a sudden after three or four visits, some clinician said, “Oh, I know what this diagnosis is,” and that changed the treatment pattern. More often than not—and I don’t think this was any necessarily a secret to any of us—it was a combination of issues that needed to be managed holistically for a patient, so homeless issues, plus mental health issues, plus access to care issues, plus medication diversion, and those sort of issues.

And when we link the information together and when we saw where people were going and how often they were seeking care for the same thing over and over again, that’s when the pattern suddenly developed. So, as an example, one of the first things that we discovered from the data that we started seeing from the program was how often these patients were presenting to outside facilities or other ERs.

So everybody in a single hospital tends to know their frequent flyers, right? “Oh, that’s Jason again. He’s always here for his back pain. He likes his narcotics, whatever it is.” And everybody knows that that’s our classic back-painer or our typical drunk. “That one’s in our ER all the time.” But one of the things that we thought and where we started to recognize is that what you thought was your frequent flyer was also spending an equal amount of time in the community emergency departments.

So, if a patient, for example, was a frequent flyer, having, say, 20 visits in your emergency department over a year, they were also having another 20 visits to the various ERs in the geography. So what you knew to be 20 visits, was actually 40 visits. And that in and of itself really magnified the scope of the problem, and it really sort of brought these patients into a lot more focus of just how much resource they were really taking up.

Gordon: So it makes me think you’re doing something different. Did you actually have to develop new types of interventions and bring new sorts of resources to bear, to deal with this.

Jason: Well, that’s where were at right now in the program. So if you dive deeper into the data—and this is where it all became a lot more interesting—we started breaking it down with Collective Medical, who’s the partner that we’ve been working with, in a number of different ways. We broke it down by diagnosis. We broke it down by utilization patterns and a number of other things.

I would say there was any number of different interesting parts that you could see from this, but one of the things that I always like to come back to was we broke patients down by how often were they utilizing the department, and we called them, for example—a high utilizer, for example, who might come in somewhere between 20 and 30 times a year. We then had a super-utilizer group that was maybe coming in up to 100 times a year, and then we had extraordinary extreme utilizers that were really in an ER basically every day. They were in one emergency department or another over 100 times a year.

And, at the beginning, when we started looking at these patients, we started—when we tried to make improvements and case manage them, we started with what we thought was a rational decision. Let’s start at the top. Let’s start with the person that’s here the most, and let’s see if we can do something about them and then work our way down. We did the top 10, and then the top 20, and then the top 50, things like that.

And, ultimately, what we found out was in a way that was a bit of a mistake. It turns out that the top 10, those extreme utilizers, they were so resource intensive, there was so much that had to be done for them that in a very realistic way the system’s sum total just wasn’t able to really enact any significant change for that. And that was unfortunate. In fact, frankly, a lot of them wound up incarcerated for one reason or another.

But the people that we started seeing that were maybe a step down from them, that were maybe a little less than 100 times a year or so, maybe, 50 times a year, or less than that, they had a combination of drug-diversion issues and mental health issues, as well as less-so chronic disease issues. And so where we’re at, right now, is trying to utilize this data across the emergency departments.

Frankly, our partners in the fire department, our partners in the police department, our partners in the mental health world to try to bring together all the resources that we can to again get these patients at the right time to the right provider or the right care that they need. And that’s where we’re at, right now, is trying to figure out what resources that we can put to the problem. Frankly, living in Los Angeles, that’s easier said than done, but that’s where we’re at right now.

Gordon: I’m intrigued. You talk about working—there’s a lot of discussion around social determinant’s health, and there are a lot of healthcare entities that are now beginning to engage with community-based organizations. And when you’re talking about people in the ER, one of those organizations are fire and rescue, the police—because you’re getting people arrested ‘cause they’re floridly schizophrenic, and acting scary in the community, and ‘cause they’re undermedicated, and they come to you—and so is that the kind of thing you’re talking about?

Jason: To some extent, that’s absolutely right. One of the great partners that we’ve had in this has been the mental health division from the LA Police Department. And so we’ve joined together with their local leadership in our local area and then brought them together to the table with the local paramedic leadership from LA Fire Department and found that linking those groups together, everybody had some resources within their organizations, but when we were able to link the resources, we realized that we were all managing the same people. Then, all of a sudden, there were some opportunities for intervention.

So, for example, the Los Angeles Police department, a number of years ago, I think, at this point, had a real initiative to stop criminalizing mental health. So trying to get these patients instead of into the jail system, which was its own revolving door, out of the jail system and into mental health care. Well, that was a great initiative, but all of a sudden, it took on a very different light when you also realize that that same patient, that the police department was maybe inadvertently criminalizing, was also in the emergency departments once a week for their psychosis or whatever.

And, similarly, the fire department resources that were being used—because the community was calling 911, for example, on the patient, the same person, that was getting agitated or aggressive—similarly, they were trying to manage the same patient. And by bringing to light the fact that we were all managing the same patient, we finally started to link in some resources to then get them, oftentimes, court-mandated psychiatric help, for example, and that was maybe a real meaningful intervention for some of these patients.

Gordon: Yeah. Give me a sort of a generic anecdote of that and how it’s different from the way it was before.

Jason: So a classic anecdote. There is a schizophrenic patient who is homeless, who has maybe a methamphetamine addiction, and tends to get agitated, get aggressive in the community when off his medications and high. That winds up with a 911 call that involves the police department, and the fire department, and then, ultimately, a visit to the emergency department where—and generally—he will spend the next 24 hours, or so, being deescalated, detoxing from his methamphetamine, psychiatrically evaluated, and then some disposition one way or the other either to a psychiatric facility or back into the community if he’s improving.

Well, that’s all well and good on an individual one-time basis, but what if you see that that same patient and that same process is now happening daily, which in some cases, it was, or even if it was once a week, do the resources in the community now sort of start screaming, and saying, “This is silly. We have to do this another way.”

And so if you then link in, maybe, some sort of intervention prior to it escalating to where it was—so, for example, the police department doing a well check on where they know that this homeless patient encamps prior to that patient getting high again, can you maybe intervene before that whole cycle starts again? And, in fact, that’s what we found. There were some social workers that were able to do that. There was interventions from social services from the fire department or the police department that were able to get out to that patient to keep that patient from cycling back into that same decompensated state.

Now, it certainly wasn’t perfect, but what we were seeing is that somebody who was maybe presenting every day, now we were getting down to if it was once every two weeks. Hey, that was an extraordinary success. Much less resources, much less time spent in the emergency department allowing us all to use those same resources for other people.

Gordon: Yeah. Walking through an emergency room, you always see there is several rooms where there are police sitting outside because there’s somebody under arrest or needing to have that kind of one-on-one attention, and I just think about the resources, and we’re paying an officer to sit in an ER, when, like you’re saying, if you can get in front of that cycle, you didn’t have the escalation; you didn’t have the arrests; you didn’t have the fire and rescue, the transport, the ED visit, the time spent there, and if you go from four a month to three a month, that’s a good thing.

Jason: That’s correct.

Gordon: It’s just everybody wins when you do that if you can pull that off. Have you had any indication of that kind of level of the successes, it paying off, in terms of—is it showing good results?

Jason: I think so. It shows results in various different ways, and this was kind of fascinating to me. One of the really great things that it showed, prior to actually showing some statistical significance in decreasing visits, which it was doing, is it empowered the ER doctors, and it empowered the staff, and so this was really important to me because—especially, with this patient population, there was a real sense of being defeated. There’s a real learned helplessness in the staff, but again “Oh, Jason’s back,” and there’s nothing you can do about that. “So we’re just going to do the same thing, and it’s just going to happen again, and why should anybody care.”

Well, this really changed that. Now, all of a sudden, and this is very real, at five different hospitals, there are multi-disciplinary committees, including case managers, and clergy, and social workers, and medical staff, and nurses who are actively case managing these patients and coming up with real-life interventions that have allowed us to, in various cases, streamline workups, or limit narcotic use, or streamline psychiatric care, and that’s been awesome to take away that sense of hopelessness and instead empower us to really try to do what we do, which is put care plans together and try to help people.

Gordon: I’m hearing meetings; I’m hearing multi-disciplinary teams, and I’m thinking that somebody’s going to sit down and say, “Hey, we’re spending a lot of resources working with this. How do we pay for it? What’s the budget?”

Jason: Yeah. And I think that’s fair. And, maybe, this is just another way that maybe the ER’s feel defeated, but, at the end of the day, I think we all recognize that we were utilizing and overutilizing resources again, and again, and again on the same people. Limiting your losses with those resources, limiting the waste was that enough of a financial impact to say, “Do it.” I think in some cases, it was, but, admittedly, we haven’t yet really approached it from a financial standpoint or a financial return on investment. Instead, it’s really been approached on from a care standpoint: “Are we getting people better care or more optimized care?”

From the resource standpoint and the finance standpoint, what we’ve done is all take the next step, and, again, that’s where we’re at right now. Can we work with the local health plans? Can we work with our Medicaid providers, which cover many of these patients? Can we work with departments of mental health, for example, and start making some sort of intervention that really puts these patients where they’re supposed to be in a way that from a financial standpoint, you can really understand the ROI a little bit better? I don’t think we’re there yet, but, hopefully, we will get there soon.

Gordon: Yeah. I’m lucky enough to sit in some conversations, and obviously reading the papers around Medicaid enrollment going up with COVID, and more people being out of work, and not having commercial insurance, and when I think about what you’re doing, the benefit to the people is so clear. There’s no question about that. It’s a good thing. Being able to sustain it is going to be based on having a revenue stream that rewards doing the right thing, and one the alignments, that I’ve seen, is in value-based purchasing, something along the lines of “Look, we can see the historic utilization pattern for a population of people.”

You can’t do this at a ad hominem person level, but you can say, “Look, we can see under this Medicaid contract that we have with Plan X that our historic utilization and spend was this amount last year or the last couple of years, and you can even get more fancy with that and hone down on a population where you can see severe and persistent melanomas, plus chronic conditions, plus use of medications, and say “Look at the spend per member per month for this population and look what we’ve done now. This is when the program started. This is where it’s going.” And that’s just the healthcare spend.

Jason: That’s right.

Gordon: I’m hearing from some programs that—Harris County, Texas and around Houston, talked to a colleague down there who is doing street medicine with homeless people and showing that he’s having salutary impact on the budgets of the police and fire and rescue because fewer arrests, and that’s a good thing. Again, fewer jail days, fewer court appearances. Again, we’re decompressing an overburdened system, healthcare and everywhere.

We don’t need to make money on doing the same thing over and over again when we’re not really helping. This is such an obvious place to go. So, hopefully, as you’re having those conversations with the plans, they can share those data. They can help you demonstrate the impact on a risk-adjusted basis to say, “Yeah, this is different. When we compare you guys to other systems that aren’t doing this work, it’s really clear.”

Jason: I think we are just now about to get to that portion of this program, where we’ve got enough history and enough historical data to be able to put together that analysis and have that discussion with the various local payers in the area, in the various local healthcare organizations in the area to hopefully come to exactly conclusions.

Gordon: So that’s sounds like that’s the next step. It’s very logical and appropriate, and it sounds like you’re right there. Do you see what the step following that might be, where do you go?

Jason: Well, I think you can go any number of different ways. I think, ultimately, at the end of the day, this becomes a very big public health conversation. What resources can we bring in the public health space that really will have an impact? In the article, we talk about the social determinants of health, and, to me, that’s where I think this winds up at some point. And it’s such a big conversation that the hope is it doesn’t become too big to just to not attack it.

But if the social determinants of health indicate—or if the data indicates that we need mental health resources, for example, in a certain geography of Los Angeles, where I’m practicing, can we make a strong enough argument with this information to do something as concrete as putting up a mental health de-escalation unit in the area? Can we do a similar thing, if you look at other social determinants of health, with homelessness situations, or we talked about food insecurity, things like that. Can we improve the food bank, for example, that’s in the local area, that’s servicing the local area, so that we can impact that part of the social determinants of the health and do we have the data and the analysis to be able to say, “This is really what we need in the geography to make some effect on this group of people.”

I think it’s a little pie in the sky, but taken one at a time, it may not be. And so that’s where I see very big picture and very long term this going. Short term, it’s a little bit more nibbling at the edges and maybe doing one at a time, slowly bringing in another mental health provider, slowly bringing more social services providers into the area, slowly connecting case managers from the various different healthcare organizations to be able to collectively case manage these patients. One at a time and slowly but surely, you wind up with an organization that all seems to be working together, and, hopefully, that gets us to the endpoint that we’re all looking for.

Gordon: I hear it. And I think it started with such a logical step which is you can’t really address it until you can see it, and you broke through the data blindness, the information inaccessibility. You made it accessible and just that started this virtuous cycle. So, excellent work.

Jason: Thank you. I appreciate it.

Gordon: So Dr. Jason Greenspan, thank you very much for your time today.

Jason: It’s my pleasure. Thanks for spending the time with me.

Gordon: You bet.

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