QUIZ 2: UTILIZATION MANAGEMENT: AN EVOLVING APPROACH TO MANAGING CARE

IDENTIFYING HIGH UTILIZERS OF EMERGENCY HEALTH SERVICES IN A COMMERCIAL HEALTH PLAN: EXAMPLE

(FROM: MANAGED CARE January 2014 . © MediMedia USA

COVER STORY

High-Utilizing Patients: Where Are the Savings?)

North Carolina Blues plan uses predictive modeling to identify high utilizers

In recent years, employers in North Carolina noticed that their workers and family members were running up high costs using the emergency room repeatedly. Seeking to control these costs, the employers asked Blue Cross Blue Shield of North Carolina to identify members using the ER frequently and to create a plan to promote using it appropriately.

For BCBSNC, overuse of the ER is an indication that care is inadequately coordinated because members are not getting the best care in the most appropriate settings, says Daryl Wansink, the plan’s director of health economics.

Overuse of the ER also can be needlessly costly. Therefore, an employer or any provider organization such as a patient-centered medical home or an accountable care organization that has the potential to share any savings from keeping costs low will seek to manage ER use appropriately, he adds.

“We have two million commercial members, and in any population this size, a fair number will be high users of the ER,” Wansink says. “The Medicaid population uses the ER more than those in the commercial population. But even in the commercial population, some may need education about when to access the ER and when to seek care in a more appropriate setting.”

For one group of employers, the effort to identify high ER users and educate them about the proper use of the health care system helped BCBSNC eliminate 1,300 inappropriate ER visits in a year, Wansink says.

What to look for

By researching patterns of health-seeking behavior, Wansink tries to anticipate which members will be high users before they actually use the ER or inpatient care excessively. “Our predictive model looks at who is a high utilizer today and we define that as anyone who has three or more ER visits in a year,” says Wansink. “These members are either very accident-prone or are using the ER for purposes that might be appropriate for treatment in other places. Once we identify this group, we look for other members with similar characteristics.”

Candidates include patients with conditions that could require immediate attention at odd hours. Asthma is an example. And patients with chronic pain could have legitimate, recurring pain or could be seeking narcotics.

“Anyone with an undiagnosed reason for chronic pain in the stomach or back could have very real symptoms or be seeking drugs,” says Wansink.

Young mothers with newborns also might be candidates. “When a mother has a baby crying at midnight and is worried, she will seek out care where she can,” he adds.

Where a member lives is another factor to consider because socioeconomic status and proximity to an ER can play a role in whether a member uses the ER, Wansink says.

Once the health plan identifies the high-utilizing patients, the staff sends them educational materials about the importance of having a primary care doctor and convenient alternative locations to receive care, such as urgent care centers. Also, nurses are available around the clock to give advice over the phone and to explain how to find the nearest urgent care center, or, if appropriate, advise the patient to visit her primary care physician during normal weekday hours, if possible.

“We have a model that predicts an inpatient admission within 12 months and a model that predicts the likelihood of a readmission within 30 days of an admission,” he says. “Then we have care managers call these members to find out what they need to help keep them well and out of the hospital.”

Predictive modeling allows BCBSNC to collaborate with providers in accountable care organizations and patient-centered medical homes to enhance the delivery of primary care to prevent excessive and inappropriate ER visits and inpatient stays, Wansink says.