Hotspotting: Rethinking Health Care Delivery

We must focus on conditions that drive over-utilization (and sometimes under-utilization) by our sickest, most vulnerable patients. This concept is only in its infancy, and it is up to our generation to be innovators.

What is hotspotting?
In an ever-evolving health care landscape, physicians, public health officials, health care managers, and insurance companies are searching for ways to simultaneously improve quality of care while reducing cost. Health care “hotspotting” has the potential to do just this, especially in vulnerable patient populations. Hotspotting is the use of data to identify high-cost patients within a defined geographic area of a health care system. These high-cost patients, sometimes referred to as super-utilizers, account for a disproportionate share of health care dollars. In fact, it has been estimated that as little as 5% of the U.S. population accounts for more than half of total health care expenditures.

While the definition may be simple, the reason these super-utilizers exist is much more complicated. To start with, patients in this vulnerable population often suffer from multiple, chronic conditions that are related to or aggravated by socioeconomic status. This, in turn, presents barriers to their receipt of effective treatment and successful medical outcomes. These barriers include food and housing insecurity, health illiteracy, educational challenges, mental health issues, and substance abuse. As a result, many of these patients languish in a system that isn’t designed to address complex and interrelated medical and social needs.

In the early 2000s, Dr. Jeffrey Brenner, a primary care physician in Camden, New Jersey, was determined to improve health care delivery in one of America’s most impoverished cities.  To do so, he pioneered the use of health care data to first identify patients who were frequent utilizers of the city’s medical system. Based on data of discharged patients, he created a searchable database to geographically map medical hotspots in Camden. Armed with this data, he then assembled an interdisciplinary team of physicians, health coaches, social workers, mental health counselors, nurses, and community health workers to address the multitude of challenges affected these super-utilizers.

Dr. Brenner’s care team, called the Camden Coalition, was a great success. In 2011, Atul Gawande, MD, MPH, reported in a New Yorker magazine article that the coalition was credited with a 40% reduction in ED visits and a 56% reduction in total hospital bills among the program’s target population. Hospital costs fell from $1.2 million per month to a little over $500,000.2 In order to build on the initial success of this treatment model, Dr. Brenner received a MacArthur “genius” grant in 2013. Dr. Brenner and UnitedHealthcare entered into a 3 year/$15 million partnership in 2017 to further refine, replicate, and improve the results of the coalition.3

The success of the Camden Coalition has led many health care systems throughout the United States to emulate the hotspotting model and develop their own programs to address the needs of super-utilizer populations. While the definition of a super-utilizer varies from organization to organization, at a minimum, it encompasses an individual with more than five ER visits or two inpatient visits within a 6-month period. Once this cohort has been identified, the real challenge lies in coordinating an interdisciplinary team of health care professionals and community groups to successfully engage with patients.

Why should we care?
Emergency physicians are on the front line of health care. We care for all-comers, with the motto any patient, any need, anytime, anywhere. All of us know the “regulars,” many of whom are plagued by more than chronic health conditions. To provide meaningful care to these patients, it's important to understand the daunting complexities of our health care system and the societal challenges that lead to ineffective treatment and suboptimal outcomes. It is our job to advocate for these patients and to participate in the interdisciplinary health care model that is taking shape throughout the nation.

As an intern for the Camden Coalition during college, working in Cooper Medical School’s free clinic, and now as the resident advisor to LSU New Orleans’ own hotspotting group, I have witnessed the barriers to care that many patients confront. Take, for example, the type 2 diabetic who repeatedly presents with hyperglycemia or in DKA. My formal training has prepared me to diagnose disease and to devise a treatment plan. But that approach frequently results in missing a key obstacle to improving the health of the most vulnerable patients. The type 2 diabetic may not be choosing to neglect his or her own care, but rather may be encountering numerous barriers to symptom control that cannot be parsed out with a simple medical exam. Therefore, it is imperative for us to learn ways to help patients navigate the barriers to effective care.

What is the future?
As our health care system is continually in flux, we must be vigilant in our study of the science of health care delivery. Our generational challenges will not be limited to identifying new approaches to ailments walking through the ED doors. Instead, we must also focus on conditions that drive over-utilization (and sometimes under-utilization) by our sickest, most vulnerable patient populations. This concept is only in its infancy, and it is up to our generation of health care professionals to be innovators and advocaters.

Hotspotting is only one approach and most of us do not have access to a team of professionals like that assembled by Dr. Brenner. Yet we can all work with our colleagues—social workers, dietitians, community health advocates, and mental health workers—to create a systematic approach to health care outcomes that serves both the medical and social needs of our patients. We must redefine the scope of health care delivery and ensure that it meets the diverse needs of the patients we are privileged to serve.

References
1. Brenner J, Doyle J, Finkelstein A, Taubman S, Zhou A. Health Care Hotspotting in the United States. The Abdul Latif Jameel Poverty Action Lab. Published March 31, 2014. Accessed July 31, 2019.
2. Gawande A. The Hot Spotters. New Yorker. Published January 16, 2011. Accessed July 31, 2019.
3. Livingston S. UnitedHealthcare taps MacArthur 'genius' Dr. Jeffrey Brenner to address high-need patients. Modern Healthcare. Published January 31, 2017. Accessed July 31, 2019.

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