Sometimes known as super-utilizers, high-frequency patients or frequent fliers, these patients typically suffer from heart failure, diabetes and kidney disease, along with a significant psychiatric problem. Some are Medicare patients unable to afford the many drugs needed to manage their chronic health problems. Others are younger "dual eligibles" who qualify for Medicare and Medicaid, and who often bounce from emergency room to emergency room, struggling with substance abuse, homelessness and related medical conditions. Still others have private health insurance.
Nearly all wind up in emergency rooms because they have enormous difficulty navigating the increasingly fragmented, complicated and inflexible health-care system. Because of lack of alternatives or force of habit, they use hospitals, often several in the same city, for care that could be provided far more cheaply and effectively in outpatient settings. Many suffer from the phenomenon known as "extreme uncoordinated care."
In the past few years, efforts to lower costs and improve care have proliferated. In Ann Arbor, Mich., two programs at the University of Michigan Health System assign specialized case managers to super-users, some of whom have been in the ER more than 100 times in a year. In a largely rural swath of central Pennsylvania, Geisinger Health System enrolls elderly Medicare patients in its Proven Health Navigator program, calling them after they leave the hospital and providing heart failure patients with scales that transmit data to nurses: Sudden weight gain can signal a problem. In the Washington area, a program sponsored by Medical Mall Health Services -- a program founded by civil rights activist and physician Aaron Shirley that targets medically underserved patients -- provides home visits and helps arrange services for newly discharged patients.
"We've seen situations where for want of a $20 cab ride to get to dialysis, a patient ended up with an emergency hospitalization costing $20,000," said Tim McNeill, chief operating officer of Medical Mall, which is headquartered in Jackson, Miss.