title: For many patients who use large amounts of health care services, the need is intense yet temporary.
abstract: Patients who accumulate multiple emergency department visits and hospital admissions, known as super-utilizers, have become the focus of policy initiatives aimed at preventing such costly use of the health care system through less expensive community- and primary care-based interventions. We conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers in an urban safety-net integrated delivery system for the period May 1, 2011-April 30, 2013. Our analysis found that consistently 3 percent of adult patients met super-utilizer criteria and accounted for 30 percent of adult charges. Fewer than half of super-utilizers identified as such on May 1, 2011, remained in the category seven months later, and only 28 percent remained at the end of a year. This finding has important implications for program design and for policy makers because previous studies may have obscured this instability at the individual level. Our study also identified clinically relevant subgroups amenable to different interventions, along with their per capita utilization and costs before and after being identified as super-utilizers. Future solutions include improving predictive modeling to identify individuals likely to experience sustained levels of avoidable utilization, better classifying subgroups for whom interventions are needed, and implementing stronger program evaluation designs.
authors.affiliation: Tracy L. Johnson (tracy.johnson@dhha.org) is director of health care reform initiatives at Denver Health, in Colorado, and an assistant professor of health systems, management, and policy at the University of Colorado School of Public Health, in Aurora.
authors.forename: Tracy L
authors.initials: TL
authors.lastname: Johnson
authors.affiliation: Deborah J. Rinehart is an associate research scientist at Denver Health and an assistant professor of medicine at the University of Colorado School of Medicine, in Aurora.
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Rinehart
authors.affiliation: Josh Durfee is a statistical research scientist at Denver Health.
authors.forename: Josh
authors.initials: J
authors.lastname: Durfee
authors.affiliation: Daniel Brewer is a senior analyst at Denver Health.
authors.forename: Daniel
authors.initials: D
authors.lastname: Brewer
authors.affiliation: Holly Batal is associate medical director of integrated behavioral health at Denver Health and an associate professor of medicine at the University of Colorado School of Medicine.
authors.forename: Holly
authors.initials: H
authors.lastname: Batal
authors.affiliation: Joshua Blum is a general internist at Denver Health and an assistant professor of medicine at the University of Colorado School of Medicine.
authors.forename: Joshua
authors.initials: J
authors.lastname: Blum
authors.affiliation: Carlos I. Oronce is a research assistant at Denver Health and a medical student at the Tulane University School of Medicine, in New Orleans, Louisiana.
authors.forename: Carlos I
authors.initials: CI
authors.lastname: Oronce
authors.affiliation: Paul Melinkovich, now retired, was director of ambulatory care services at Denver Health.
authors.forename: Paul
authors.initials: P
authors.lastname: Melinkovich
authors.affiliation: Patricia Gabow is a professor of medicine at the University of Colorado School of Medicine and, now retired, was CEO at Denver Health.
authors.forename: Patricia
authors.initials: P
authors.lastname: Gabow
mesh_terms: D000328:Adult; D003120:Colorado; D003430:Cross-Sectional Studies; D005102:Health Expenditures; D006296:Health Services / Q000706:statistics & numerical data*; D006297:Health Services Accessibility; D017722:Hospital Charges / Q000639:trends; D006760:Hospitalization / Q000191:economics / Q000639:trends; D006801:Humans; D008137:Longitudinal Studies; D017057:Medically Uninsured; D012959:Socioeconomic Factors; D014505:Urban Population
keywords: Cost of Health Care; Determinants Of Health; Health Spending; Organization and Delivery of Care; Safety-Net Systems