To improve quality and reduce
cost through coordination of care for the
most costly and vulnerable in our health care system.
Published On: March 10, 2015 in the Houston Chronicle
Intensive users of medical
services account for 21% of the Medicaid budget in
Four patients used emergency rooms at 19 different Houston
hospitals a total of 179 times last year, according to
Primary Care Innovation Center, a Houston
nonprofit. One patient has a total of 56 visits to 10
different emergency rooms. These intensive users of medical
services - in the jargon, "super-utilizers" - account for 21
percent of the Medicaid budget in Texas, according to Primary Care
One typical super-utilizer has no primary care physician and
suffers from a variety of conditions such as diabetes, hypertension
and gout, to give a few common examples. Some experience
dimentia. When faced with a health crisis, such as a high
spike in temperature, the super-utilizer heads to the emergency
The super-utilizer may receive a MRI or CAT scan at an emergency
room even though a similar expensive test was conducted at a
different emergency room weeks earlier. Discontinuity of care
- or overlap in care - can be harmful, as well as expensivc.
For example, the most recent emergency room physicians may not have
a record of the patient's existing medications, and the patient may
not be able to recall all of them. The patient may receive a
prescription for new medication that conflicts with his existing
The irony is that despite their many hospital visits, the
super-utilizers receive poor care; their chronic conditions are not
suited for treatment in emergency rooms. As an over-reliance
on emergency centers is expensive, the taxpayer loses, too. A
strategy to identify these patients and improve their care is
essential to drive down health care costs.
The Primary Care Innovation Center has develped a pilot program,
and its initial results working with such patients are
encouraging. In the first three months, the costs of emegency
room visits by the super-utilizers enrolled in the program and
ambulance transport dropped 85 percent from the previous three
Althought he nonprofit has not yet duplicated its results in a
large population, its strategy makes sense. Nurses, social
workers and other caregivers work with super-utilizers to solve the
underlying problems that contribute to these patients'
over-reliance on the emergency care system, such as lack of
transportation, housing and education.
Other similar program across the U.S. have shown dramatic
decreases in the utilization and related costs of emergency room
care. Texas needs this kind of cost-saving innovation, as the
average Medicaid expense of its super-utilizers is 50 percent more
than the rest of the U.S., according to Dr. David Buck, president
of Primary Care Innovation Center and professor at Baylor College
of Medicine's Department of Family & Community Medicine.
Our various hospital systems need to work to identify these
super-utilizers and coordinate their care. This will require
overcoming barriers to the sharing of medical records and to
standardizing databases. The Legislature should act to
provide adequate sources of reimbursement for Medicaid services to
maintain continuity of primary care. All state leaders should
spend more time listening to physicians with innovative ideas -
such as Dr. Buck - and less time lecturing federal officials.
Texans would benefit from more efficient use of tax dollars, and
Texans with chronic conditions would receive better care.