Governors Band Together to Address Health Care “Super-Utilizers”

As Medicaid expands, so does the need for finding quality health care at lower cost, and one big thing each state must contend with is what to do with a “super-utilizer.” Over the past few years, much research has been done to identify these Medicaid recipients, who frequently use the emergency room, hospital inpatient services, and other high-cost forms of health care delivery instead of coordinated, lower-cost interventions. Finding the perfect way to care for these super-utilizers might just be the ticket for state officials to address rising Medicaid expenditures while improving quality of care and health.

State Research

The National Governors Association recently announced that it will fund seven states in a collaborative effort to design and improve state-level health systems to ensure better provision of coordinated and targeted services for “super-utilizers.” The selected states and Commonwealth are Alaska, Colorado, Kentucky, New Mexico, Puerto Rico, West Virginia and Wisconsin. This “Developing State-Level Capacity to Support Super-Utilizers” policy academy, is designed to assist states in creating the regulatory environment, data systems, workforce, financing structures, and stakeholder relationships to support the delivery of high-quality and comprehensive services for super-utilizers.

Colorado Governor John Hickenlooper is excited about the prospects. “This collaboration will allow us to better respond to the unique health needs of individuals,” he said. “Colorado’s goal is to become the healthiest state in the nation by achieving the best care and producing the best health outcomes with the best value, and this will get us one step closer.”

Kentucky Governor Steve Beshear announced, “I’m proud Kentucky has been chosen to participate in this important program.” “Across the nation, an understanding has been growing that we must focus our efforts on providing the best in coordinated care, helping to direct individuals who may be using more expensive, less effective services to more cost-efficient preventive services that provide better health outcomes in the long run. It’s by achieving these outcomes that we will build a healthier future for Kentucky.” Kentucky’s Medicaid program spent more than $219 million on emergency room (ER) use in 2012. In that 12-month span, 4,400 Medicaid recipients used the ER 10 or more times, including a recipient who visited the ER 121 times and another who used 30 different ERs.

A policy academy is a highly interactive, team-based, multi-state process for helping a select number of states develop and implement an action plan to address a complex public policy issue. Participating states receive guidance and technical assistance from NGA staff and faculty experts, as well as consultants from the private sector, research organizations, and academia. Funding for the policy academy is provided by the Robert Wood Johnson Foundation and the Atlantic Philanthropies.

Staggering Statistics

CMS has just issued an Informational Bulletin sharing details about super-utilizer programs, revealing just how important it is that states figure out a way to deal with this issue. Within the Medicaid program, 5 percent of beneficiaries account for 54 percent of total Medicaid expenditures, and 1 percent of beneficiaries account for 25 percent of total Medicaid expenditures. Of this top 1 percent, 83 percent have at least three chronic conditions and more than 60 percent have five or more chronic conditions. While people with serious chronic conditions or an acute illness are expected to have higher utilization, CMS noted that there is growing evidence that some of these high-cost patients are not receiving coordinated care, preventive care, or care in the most appropriate settings.

CMS pointed out that the fundamental question, of course, is whether a super-utilizer program truly is likely to be successful in improving beneficiary outcomes and reducing unnecessary spending. States will need to determine what payers are involved and who provides the services. States must decide on a “targeting strategy” to identify potential patients. CMS noted that a successful program identifies candidates that are likely to experience high levels of costly but preventable utilization in the future and that are capable of being helped by the specific capabilities of the program.