All squares are rectangles, but not all rectangles are squares. According to a recent study, the same logic applies to patients: Not all of those who accrue high costs are so-called “hot-spotters,” that is, patients with chronic diseases who frequently utilize inpatient and emergency services.
Researchers assessed the records of nearly 15,000 Medicare fee-for-service patients who received at least 90% of their primary care services at a Cleveland Clinic Health System facility in 2012. They identified 5 categories of high-cost patients: ambulatory (no admissions), surgical (median of 2 surgeries), critically ill (median of 4 ICU days), frequent care (median of 2 admissions, 3 ED visits, and 29 outpatient visits), and mixed utilization (median of 1 admission and 1 ED visit).
Just 9% of high-cost patients were hot-spotters (defined as having 4 or more hospitalizations, ED visits, or both during the study year), and they accounted for 19% of the high-cost population's costs (11% of overall costs), according to the analysis, published online in August by the Journal of General Internal Medicine.
“People have consistently told me that what we describe in our paper is consistent with what they've observed in practice,” said lead author Natalie S. Lee, MD, MPH, ACP Member, an internal medicine resident at Cleveland Clinic in Ohio. She recently spoke with ACP Hospitalist about the implications of her work.
Q: Why did you decide to study this issue?
A: At the time, I was very interested in care coordination and studying what would make care coordination cost-effective. Looking through the available literature, I noticed that care coordination didn't consistently result in cost savings. So then I began to wonder why that was the case, who they were targeting, and who those high-cost patients really were.
Q: What are the most important takeaways for hospitalists?
A: I think one of the key observations of our study was that we should not be focusing on hot-spotters alone. We also need to think about the components of care that are very expensive, like critical illness, chemotherapy, or surgery. That means physicians can impact cost savings not only by thinking of ways to prevent admissions, but also by engaging in patient-centered, judicious use of these very expensive, valuable resources. That includes things like weighing treatment options based on the cost versus marginal benefit of the therapy, or the appropriate initiation of discussions about palliative care rather than sending a patient to the ICU.
Q: How might your study influence hospitals' cost-reduction strategies?
A: It probably highlights the need to understand and address drivers of high-cost care. It's obviously a very tough problem for which we don't have immediate answers. I guess things that hospitals or health care systems could try to do include promoting price transparency, promoting marketplace competition for drugs like chemotherapies or medical and surgical devices, and encouraging the overall development of disruptive innovations to reduce the very high costs of certain resources.
Q: Are interventions that specifically target hot-spotters still useful?
A: Definitely. For one, I think it is the right thing to do, to focus on understanding and meeting the needs of patients who really require close medical supervision and have multiple complex comorbidities. In our study, hot-spotters still accounted for nearly 20% of the costs incurred by high-cost patients, so their costs to society are very significant. But what I think our study highlights is that when it comes to effectively reducing costs, we should not be focusing on hot-spotters alone.
Q: Why has the proportion of hot-spotter patients been estimated to be higher in the past?
A: I can think of a couple reasons why our results are different from previous estimations. One is a limitation of our study: We looked specifically at the Medicare population. I think it would be interesting to see the proportion of hot-spotters among high-cost Medicaid patients specifically versus among privately insured patients. I don't think it would be surprising if the proportion of hot-spotters were different in those populations. I think the second reason is that some of this has been obscured by data that, on average, high-cost patients tend to have more admissions than low-cost patients. So high-cost patients are automatically thought to be hot-spotters, and it's actually fairly common to read and hear the term “hot-spotter” used interchangeably with “high-cost.” We came across a very limited number of studies that attempted to really tease out the differences in utilization within the high-cost population, and I think it probably just underscores our lack of a refined understanding about who high-cost patients are.
Q: How might your study change how health care perceives high-cost patients?
A: It challenges the common conception out there that a patient has to be admitted frequently to be a high-cost patient. Even in the process of gathering data, people would frequently say, “You probably only need inpatient costs because all the high-cost patients are admitted.” We found that was not necessarily the case. So I think this means that we have to step back and reevaluate our expectations for reducing costs just by investing in ways to reduce admissions. It's just as critical to invest in understanding and addressing the other factors that make high-cost patients so expensive.