Rural Health Value (RHV) is a national initiative funded by a cooperative agreement from the Federal Office of Rural Health Policy (FORHP) with the RUPRI Center for Rural Health Policy Analysis (RUPRI Center) and Stratis Health.
A small percentage of patients utilize a disproportionate share of health care services in the United States. In 2013, 5 percent of patients accounted for 50 percent of total health care spending. ED utilization reflects similar health care spending proportions. Although similar data are not available for rural EDs, disproportionate utilization of an annual 28.4 million rural ED visits in 20162 by a small percentage of individuals is likely.
A patient who disproportionately utilizes ED services is considered a “high need/high cost” (HNHC) patient. Although there is no standard definition of a HNHC patient, a Centers for Medicare & Medicaid Services bulletin defined HNHC ED patients as “patients who accumulate large numbers of ED visits and hospital admissions which might have been prevented by relatively inexpensive early interventions and primary care.”
Most HNHC patients have at least 1 psychiatric diagnosis and 1 or more chronic illnesses.5,8 HNHC patients also experience significant barriers to accessing routine health care, including homelessness, substance abuse, severe chronic illnesses, physical disability, dental disease, early life trauma, and mental health problems. Due to mental health issues and chemical dependency, many HNHC patients have difficulty navigating the health care system and keeping scheduled health care provider appointments. Additionally, HNHC patients may have had negative experiences with providers during prior encounters.5 Nearly 60 percent of Medicaid beneficiaries who were among the most expensive 10 percent in 1 year remained among the top 10 percent in 2 subsequent years
HNHC patients present to the ED primarily with low acuity and chronic disease concerns. Behavioral health issues, substance abuse, and social isolation factors often complicate the clinical situation. The HNHC patient clinical and social profile therefore suggests the need for robust primary care, care coordination, social services, and health advocacy. In contrast, ED care is designed to treat acute, episodic, and emergent clinical situations. Therefore, ED care inadequately meets HNHC patient care needs.
Many have called for health care to be at the right place, with the right provider, and at the right time. The ED is generally the wrong place and the wrong provider for typical HNHC patient health care concerns. Care should also be at the right price. Repeated ED care is likely to be more expensive than care coordinated with the primary care office and in the community.
To address inadequate and inappropriate patient care, and to reduce health care costs, HNHC patient programs have been implemented to provide patient‐centered interventions to improve overall health, bolster care coordination, reduce overutilization, and decrease health care spending through directed care management of HNHC patients who disproportionately use health care services. Hospitals generally establish HNHC patient programs, although other organizations (e.g., payers or social service agencies) can also do so. Regardless of organizing entity, HNHC patient programs have the potential to impact hospital ED utilization and financing.
This paper describes HNHC patient program design, implementation, operation, and assessment
HNHC patient program design begins with outlining program goals. Explicit program goals will define program data requirements and the program evaluation process. Program goals (and associated indicators in parentheses) may include the following:
• Decreased ED visits (ED visits per HNHC patient) • Decreased payer costs (hospital revenue received from payer)
• Increased primary care visits (primary care visits per HNHC patient)
• Decreased hospital inpatient admissions (hospital inpatient admissions per HNHC patient)
• Decreased hospital charges (hospital ED and associated ancillary charges)
• Decreased uncompensated care charges (charge‐to‐revenue ratio)
• Decreased hospital costs (allocated hospital costs)*
• Increased hospital revenue (e.g., grant funds, care management fees, and other revenue sources)
• Increased patient satisfaction and/or self‐perception of health (patient surveys )
In summary, HNHC patient programs likely reduce payer costs, although not all additional outpatient costs have been considered. Conversely, HNHC patient programs likely reduce hospital revenue derived from ED service payments. To optimize the financial benefit of HNHC patient programs, payers, hospitals, and other providers should develop shared savings or global budget agreements.
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