Big Data Helps Identify Heaviest Healthcare Users

In the past several months, I’ve had the opportunity to discuss trends in the healthcare industry with some of the best minds in the business, and one topic keeps coming up – population health. What has surprised me is that everyone I talked to places a different emphasis on aspects of the larger concept. It’s as if there isn’t a universal agreement on the definition of population health.

I think it’s safe to say that the focus of population health is to improve chronic disease management, reduce risk factors and improve gaps in care, but there are a number of strategies available to reach those goals.

One strategy I found intriguing is the use of big data to identify patients who use the system the most. That’s important because a small percent of patients often uses a disproportionate amount of healthcare resources. In some communities, such as Camden, N.J., 1,000 patients – one percent of the population that used the city’s medical facilities in the early 2000s – accounted for 30 percent of its healthcare costs.

And yet, research has shown that simply making healthcare available to chronically ill patients doesn’t necessarily reduce costs. Although heavy users of emergency departments could reduce their need for emergency visits and hospital admissions simply by having alternative treatment options, mitigating life factors often have a determining influence on their choices. For example, a patient’s living conditions, mental abilities, caregivers or bad habits such as smoking and drug abuse can contribute to poor health and an over-reliance on emergency treatment, even when access to traditional healthcare is available. 

Once a system is able to identify the heaviest healthcare users, hospitals and clinics can create teams to monitor those patients. Teams are essential to providing safe, appropriate care to patients who are chronically ill. Engaging these patients before their health issues become critical and require emergency treatment is a key to delivering appropriate care that is also cost-effective care. Team members can include physicians, nurse practitioners, social workers, “health coaches,” and sometimes support staff, such as the receptionist at a neighborhood clinic. 

Each team member has a role to play in a patient’s overall care. For example, regular visits with a doctor are included in follow-up plans after discharge, but nurse practitioners can conduct longer visits more often than regular office visits. They can follow up with phone calls, educate both patients and caregivers, and try to address problems before the problems require a hospital visit. Social workers can help find better living arrangements and access to appropriate health insurance. Health coaches, a new job description created in one Atlantic City clinic, are based on the community health worker model and can help follow a patient very closely, sometimes every two weeks. Health coaches often come from the patient’s community and understand the patient’s culture. 

Both engaging patients in their own care and enlisting help from the patient’s family whenever possible are vital in helping to improve the health of chronically ill patients, and education is a key resource. Learning about exercise, stress reduction, and healthy living, for example, is often very helpful in improving health and avoiding difficult, costly hospital stays or emergency room visits.

Without adequate compensation for medical teams and hospitals, however, it will be difficult, if not impossible, to improve the health of communities. CMS has recognized the importance of aftercare and has begun reimbursing for following a patient after a hospital stay to the next level of care – home, rehab center or long-term care facility under certain conditions.  Not everyone discharged after a hospital stay is eligible, but adding reimbursement codes for follow-up care is a step in the right direction. 

Addressing the needs of chronically ill patients and creating medical teams to follow their care are only two strategies in the overarching concept of population health. Improving population health, however, is central to the goals of healthcare reform: better care for individuals, better health for populations, and lower costs for healthcare overall.