Please refer to the below for more detailed information about the low-income, high-need super-utilizers and their challenges.
Who are super-utilizers?
Within the publicly financed health care system, a small percentage of low-income individuals are responsible for utilizing a disproportionate amount of services – over 55 percent of Medicaid expenditures are driven by only five percent of beneficiaries. These individuals struggle not only with multiple chronic conditions—including high rates of mental illness and substance use disorders—but also with significant social and environmental challenges such as poverty, homelessness, and social isolation (also known as social determinants of health). Often referred to as ‘super-utilizers,’ or high-need, high-cost populations, these individuals typically lack strong ties to primary care—instead, frequenting the emergency department (ED) for care and often being admitted for inpatient treatment. They may utilize services across a variety of different hospitals or clinical settings, leading to fragmented care that does not address the “full picture” of their needs.
Super-utilizers are often difficult to locate because of their unstable home and financial situations (their addresses and phone numbers change frequently). Even if located, it often requires a tremendous amount of work on the part of care managers, social workers, and/or providers to engage these individuals to the point where they receive consistent care. This is due to several factors, including that many of them have previously had negative experiences with the health care system and are deeply mistrustful of providers and the health care system.
The lives of many of these individuals are quite chaotic, and many are unable to proactively manage their health and plan for the future—instead jumping from one crisis to the next. There is mounting evidence suggesting that a large number of these individuals have likely experienced some sort of physical, emotional, or sexual trauma at some point in their lives, which is directly correlated with poorer health outcomes and decreased ability to effectively plan for the future. It is also typical for these individuals to touch a wide variety of social safety net organizations and agencies, including the criminal justice system, supportive housing or shelter services, adult and/or child protective services, and food assistance, to name only a few.
Why focus a developer challenge on super-utilizers?
Only a fraction of digital tools currently on the market target super-utilizers—likely due in large part to the perception that low-income individuals are not a profitable market on which to focus. However, several recent studies show that low-income populations increasingly own phones—including smart phones. A 2012 Pew Research Center study found that 34 percent of individuals with an annual household income of less than $30,000 had smartphones. At the same time, 55 percent of individuals with an annual household income of less than $30,000 own basic cell phones. Current trends suggest that low-income individuals will increasingly become smartphone owners as the technology becomes cheaper and more widespread.
There are also strong economic forces at play that make tools to help manage this population’s health care utilization (and thus, costs) exceptionally valuable to insurers—and perhaps even local and state governments. With the advent of the Affordable Care Act, over half of the states in the US have expanded their Medicaid programs, meaning that more of these high-cost super-utilizers have health care coverage than ever before. Many of these individuals are enrolled in Medicaid via managed care plans. These plans contract directly with states (which administer the Medicaid program) to receive a set “per-member, per-month” (PMPM) fee, also known as a capitated payment, to manage their members. Under this arrangement, plans “bear risk” for patients, meaning that if a patient uses more services than the PMPM rate covers, the plan pays the difference. Both plans and states are therefore financially motivated to keep members healthy and seek out tools that help them do so. One program serving this population, the Camden Coalition of Healthcare Providers, estimated that its highest-utilizing members averaged 4.5 ED visits and 5.3 hospital admissions per year, resulting in 54 days a year spent in the hospital, at an average annual cost of $73,000. The federal Agency for Healthcare Research and Quality estimates that a standard Medicaid inpatient admission in 2010 cost $7,500, and that number has almost surely gone up in the years since. These numbers highlight the ways in which tools that can reduce the number of hospital admissions for this population—even just by one per year—offer health plans an opportunity for tremendous aggregate savings.
To learn more about technology ownership rates and how Medicaid works, please review the materials under “Technology and the Underserved” and “Understanding Medicaid” on the Resources page.
What are some of the issues faced by super-utilizers that developers can work to address in their products?
With this challenge, the Center for Health Care Strategies is eager to entice developers and entrepreneurs to focus on a currently underserved market in the digital health world. We seek to illustrate that this is not only a viable, but also profitable space (for purchasers and companies)—and that tools targeting complex, low-income populations can improve health outcomes and reduce costs.
Entrants should address one or more of the below problems, and for each, consider that low-income, high-need super-utilizers are a difficult population to engage, with multiple medical, behavioral health, and social issues. These individuals also require products designed with both literacy in general (products should be designed for a 5th grade reading level) and health literacy specifically in mind (see “Resources” for more information). In addition to addressing these problems, entrants should use their videos to contextualize their solution by addressing the ways in which their product will directly and positively impact at least one of the challenges faced by Mary, the patient described in the Case Study.
Eligibility and Coverage Management
Low-income individuals often qualify for a variety of benefits programs, such as Medicaid, Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps), home energy assistance, etc. Eligibility for these programs, including Medicaid, typically needs to be verified on an annual basis, and may change based on individuals’ financial or medical circumstances. For instance, some states have Medicaid “spend down” programs that allow individuals who are not low-income enough to qualify for Medicaid – but who have high medical expenses – to receive Medicaid coverage after a certain amount of their money has been spent in a given month. Members of this population often face challenges such as: (1) determining which public benefits programs they qualify for; (2) accessing or completing these programs’ enrollment processes; (3) receiving notification of when they need to reapply or submit new documentation; and (4) tracking their Medicaid “spend-down” status. These issues are particularly challenging for individuals who are unstably housed or homeless, as mailed notifications frequently do not reach them. Solutions aimed at addressing Eligibility and Coverage Management should seek to provide real-time information to individuals about eligibility and coverage, and address challenges in the enrollment/application process.
Chronic Disease and Care Management
Super-utilizers are often diagnosed with multiple chronic health conditions, as well as behavioral health and substance use disorders. Managing these conditions is a challenge for anyone, and even more so for individuals who are socially isolated, unstably housed, and/or struggling with untreated, undiagnosed, or poorly managed behavioral health disorders. Many individuals in this group are often linked with care managers and/or care teams that help in developing a care plan that identifies needs and goals, and providing support in achieving these. Technology is increasingly allowing individuals to manage their own health care, and super-utilizers could benefit greatly from tools that empower them to better understand and manage their conditions. Solutions aimed at addressing Chronic Disease and Care Management should focus on facilitating this, as well as helping patients and care managers stay connected between appointments and supporting patients and care teams in working together to manage their conditions. Entrants should consider how the social determinants of health – such as housing instability and social isolation – may be impacting individuals’ ability to manage conditions and work with providers. Developers might also propose tools for medication management, goal attainment, remote patient monitoring, and patient engagement.
Hand-Offs, Transitions in Care, and Connections to Social Services
Super-utilizers often receive care from multiple service providers and organizations, but frequently these providers do not coordinate with one another, resulting in fragmented care. This may lead to patients “slipping through the cracks” when transitioning from one care setting to another – for example, being discharged from the hospital to their home or another care facility. Similarly, individuals who may benefit from linkages to social services may not be aware of the resources or organizations available to them, or may have a hard time following through in accessing services. On the other hand, some of these organizations may have difficultly contacting or keeping up with these individuals due to frequent change in phone numbers and addresses. Entrants who want to tackle Hand-Offs, Transitions in Care, and Connections to Social Services should develop products that focus on: (1) improving communication among doctors and other care team members, both within and across organizations; (2) linking individuals to appropriate community resources outside of the health care setting; and/or (3) helping organizations maintain contact with hard-to-reach individuals.
High-need, high-cost individuals, particularly those managing multiple chronic conditions, often receive care from numerous medical providers and specialists, as well as from social service organizations. It can be difficult to schedule, track, and remember appointments, particularly when they occur across multiple systems without a unified scheduling system. This in part contributes to a high no-show rate among this population, which in turn frustrates providers and leaves them less willing to see super-utilizers in the future. This multitude of appointments also means that this population spends a lot of time in waiting rooms. Long wait times can lead patients to feel frustrated and unmotivated to show up to appointments, but they also present a potential opportunity to engage patients in this setting. Entrants wishing to address the issue of Appointment Management should consider ways to ease the challenge around scheduling, and/or address the issue of wait times (either how to lessen them or leverage them into educational/engagement opportunities).
Access to Health and Wellness Resources
Access to health and wellness resources may be a challenge for super-utilizers for a variety of reasons, including: geographic distance from services or resources; lack of reliable transportation to services or activities; difficulty finding child care; inability to afford healthy foods or gym memberships; lack of knowledge about choosing/preparing healthy foods or options for exercise, among others. Solutions seeking to tackle the challenge of Access to Health and Wellness Resources should focus on connecting individuals to resources and services such as healthy foods, reliable transportation, and wellness activities. These solutions could also address the knowledge gap related to selecting and preparing healthy foods, and/or tailoring exercise for individuals with chronic conditions.