Healthcare News & Insights

How to curb Medicaid ‘super-utilizers’ in hospitals

The feds are placing their focus on cutting healthcare costs, and one specific segment they’re targeting is Medicaid “super-utilizers” who get most of their health needs met in the hospital emergency room setting.

91288734These patients are small in number, but contribute the most to healthcare spending. According to a bulletin released by the Centers for Medicare & Medicaid Services (CMS), 5% of Medicaid beneficiaries account for 22% of Medicaid spending – and just 1% of Medicaid patients account for 25% of Medicaid costs.

Hospitals that serve disadvantaged populations are more likely to deal with higher volumes of these frequent users, who often have several chronic conditions that are only managed through hospital visits. In addition, these patients may have a higher likelihood of mental illness or addiction problems.

Strategies for hospitals

As a way to keep these patients from being such a financial burden on the healthcare system, CMS has proposed several strategies hospitals can use. The key concept in these strategies is forming partnerships with primary care physicians and various healthcare providers to give patients better access to consistent care, along with other essential health services such as mental health resources and substance abuse counseling.

In that vein, CMS is giving funding to several hospitals to develop programs based on this principle to cut costs by providing Medicaid patients with a better continuum of care.

Example: Cooper University Hospital in New Jersey was recently given $2.8 million to expand its Camden Coalition program. For the past 10 years, the hospital has partnered with physician practices and other providers to improve the care for disadvantaged residents in Camden, NJ – and the program has led to reduced ER visits and inpatient stays.

For a program like this to work with underserved and disadvantaged patients in your hospital, several steps must be taken:

  • Identify the patients served. You’ll want to know how much of your patient mix falls in the disadvantaged category and whether they’re receiving Medicaid or are uninsured entirely.
  • Know what’s causing them to constantly seek hospital care. What conditions do these patients have that cause them to keep returning to the hospital? What other mitigating factors come into play with their decisions?
  • Target the issues. After finding out exactly what keeps bringing these patients to the hospital, try to come up with solutions that will reduce their visits, focusing on their specific issues and challenges. Get input from various providers.
  • Run a cost/benefits analysis. Make sure your hospital is fully aware of the immediate cost that can be incurred by such interventions, along with the potential benefits and savings down the line.

While this effort may prove time-consuming and costly at first, it will likely save money for your hospital in the long run by having a more efficient and cost-effective way to handle underserved patients. Keeping the patient load lower will have other bonuses as well, including improved staff productivity and less crowding in the ER.


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  1. This is incorrect. 5% accounts for 54% of Medicaid Spending and 1% accounts for 25% of Medicaid spending…. bad job reporting.
    1% of the population accounts for 22 percent of total health care expenditures annually.