How hospitals can control Medicaid 'super-users'

Small group of patients make up most of Medicaid spending
Tools

Hospitals can cut costs and improve patient care by setting up care delivery models that target Medicaid patients who have complex, unaddressed health issues and a history of frequent encounters with healthcare providers, according to The Center for Medicaid and CHIP Services (CMCS).

These Medicaid "super-utilizers"--patients who accumulate large numbers of ED visits and hospital admissions that might have been prevented by inexpensive early intervention and primary care--are a relatively small group, yet they account for the majority of Medicare spending, CMCS said in an informational bulletin issued this week. According to CMCS:

  • Five percent of Medicaid beneficiaries account for 54 percent of the program's total expenditures
  • One percent account for 25 percent of the program's total expenditures
  • Eighty-three percent of the top 1 percent of users has at least three chronic conditions
  • More than 60 percent of the top 1 percent has five or more chronic conditions

But CMCS said the success of 10 programs across the country that have targeted these Medicaid super-utilizers indicate that early intervention and primary care can save money while improving the health outcomes of these complex patients. The agency highlights the details of six of the 10 programs in its 39-page informational bulletin.

In addition, the bulletin suggests six questions hospitals and states should consider prior to launching similar programs.

Interest in super-user programs is increasing across the public and private sectors, according to the agency. For example, The Center for Medicare and Medicaid Innovation (CMMI) recently awarded Health Care Innovation Awards to two initiatives targeting Medicaid super-utilizers.

Cooper University Hospital in New Jersey received $2.8 million to expand the Camden Coalition super-utilizer program to serve more than 1,200 patents with estimated three-year cost savings of $6.2 million. Rutgers, the State University of New Jersey, was awarded $14.4 million to test community-based super-utilizer models led by safety-net provider organizations in Pennsylvania, Colorado, Missouri and California with estimated three-year cost savings of $67.7 million.

In addition, the Robert Wood Johnson Foundation is funding super-user programs in six communities in New Jersey, Ohio, Maine, California, Massachusetts and Michigan. These programs include community-based super-user teams that focus on the highest utilizers in a specific geographic area and super-utilizer clinics/ambulatory intensive care units that care for patients with the highest utilization.

For more:
- read the CMCS informational bulletin (.pdf)

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