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President's Message: Focus on the Highest Utilizers

by Claire Levitt, MS
President, Alicare Medical Management
Claire Levitt

In the midst of the whirlwind of politics surrounding the future of healthcare reform, those of us who work in care management have to remain focused on addressing patient care and healthcare cost issues right now, including when and where they occur. Many of the initiatives emerging from the healthcare reform legislative changes can help us address the long-term health of our nation with better preventive care benefits and improved access to care. But the patients we deal with every day can't wait, especially those with the most intensive healthcare needs who are generating the highest costs.

At Alicare Medical Management, we address those issues one patient at a time each day. Through our years of case management experience, we've learned we can have the greatest impact on health and financial outcomes by proactively focusing on the health needs of our highest utilizing patients in collaboration with their providers and payers.

Likewise, in a provocative article that ran in the January issue of The New Yorker - called "The Hot Spotters" - Atul Guwande posed the question, "Can we lower medical costs by giving the neediest patients better care?"

He offered encouraging and innovative examples of how physicians, data analysts and health coaches used data to identify and target the highest utilizing patients and achieved significant reductions in hospitalizations and emergency room visits. Guwande focused on three such initiatives where targeting "super-utilizer" populations of low income, high-cost patients whose health had been neglected, resulted in significant expense reductions by helping them gain access to better and more focused healthcare treatment and impacting the behaviors that contributed to their poor health.

How do we do this for our clients? Our integrated approach to patient care provides a strong foundation for this strategy. First, we use technology to identify these high-risk, high-use individuals using clinical information like hospital and ER admission data available to us from our core utilization management programs. Our nurses also collect information through comprehensive health-risk assessments, patient interviews, nurse line calls and clinical data from Alicare Medical Management's medical management system to identify utilization patterns and risk factors and for each client population and each patient. We then rely on evidence-based assessment tools and other data sources to build an individualized care treatment plan that our nurse health coaches can implement with our high utilizers. That's where high-tech meets high-touch. It's ultimately the one-on-one coaching by a nurse that becomes the catalyst for the behavior changes in lifestyle and utilization that can improve patient outcomes and drive costs down.

What does this look like in practice? Here's a real-life example from Alicare Medical Management's files where the case manager's ability to generate collaboration between the patient, provider and payer resulted in better clinical and financial outcomes.

A 64-year-old patient with diabetes, cellulitis, asthma and hypertension was admitted to the hospital three times in less than six months for uncontrolled diabetes incurring over $150,000 in costs. System triggers identified him as a high utilizer based on his diagnoses, high-cost claims and the multiple admissions. Our nurse case manager reached out to the patient and learned that he had not been compliant with his medication regimen due to the high copayments required for his brand name prescriptions. Working with his physician, the case manager arranged for generic replacements for certain medications and for his coverage to waive the copayments for other medications in the interest of controlling costs. In addition, the case manager coordinated a treatment plan for the patient that included educational sessions with a dietician, training on the use of a glucometer and ongoing health coaching. Since this patient became compliant with his medications, learned how to control his diet and monitor his blood sugar, he hasn't been hospitalized in more than a year.

This type of outcome is a "win-win" for patients, providers and payers. When the patient gets the right care at the right time and place, we all see how better clinical outcomes go hand-in-hand with better financial outcomes. Better care and lower costs should not be a contradiction.

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