Diverting High-Cost Frequent Flyers: Population Health Tactics to Manage High Utilizers

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Normally, the word “diversion” conjures images of sleep-deprived arrivals at regional airports; an experience to be avoided at all costs. In medicine, however, diversions — from emergency departments, inpatient settings, specialist visits, and urgent care clinics — are to be embraced for their cost-mitigation attributes.
A quick Google search returns hundreds of pieces written over the past three decades about high-utilizers — cynically dubbed “frequent flyers” — and strategies for managing this complex subset of a physician’s patient panel. Defined as patients with 8+ ED visits or 3+ hospital-admissions in the past year, these patients are estimated to represent 5% of the patient population and account for 50% of the country’s annual medical spend. Shockingly, 1% of these patients spend $88,000 per year on medical expenses.
Intimately familiar with the rhythms of a hospital, and often on a first-name basis with staff, these patients can pad the bottom line for hospital executives in annual reports. Crucially, however, these visits accomplish little in terms of improving quality of care and cost-savings for the broader healthcare system. Focusing on moving patients away from high-cost and low-quality care settings is a challenging but foundational building block in any Population Health management program.
Given the characteristics of the high-utilizing patient populations, identifying and managing frequent flyers can be confounding. Couple that with insufficient incentive models, and doing so becomes a non-starter for most independent primary care clinics. Fortunately, recent developments have shown investment in preventative care activities can pay off, as payers become increasingly interested in controlling costs, in part by rewarding physicians for work they’ve always done.
Difficulties inherent in managing complex and high-utilizing patient populations
Several barriers stand in the way of successfully diverting patients from high-cost care settings. For one, the nature of the patient-physician relationship can be challenging. In addition to physical ailments, chronically-ill, complex patients often suffer from mental health issues, making them difficult to engage with and retain as a patient year over year.
If a patient does stick with their physician, the severity of their conditions can wane from year to year, making it difficult for practitioners to know where their high-cost patients will crop up next. Accurately predicting who will need personalized, white-glove treatment next can be a challenge for physicians hoping to stay ahead of their patient’s needs and keep them out of hospitals.
Lastly, more work needs to be done to understand the full scope of the frequent-flyer problem in the United States and how it can be most effectively managed. Anecdotal evidence (and common sense) suggests addressing patient’s chronic illnesses before they require expensive hospital visits should deliver lower costs and better outcomes for patients.
Much of the hard data compiled over the last ten years is limited in scope to low-income populations, and does not have the benefit of multi-year, patient-centered, controlled studies to draw from. The formal studies that do exist, however, show promising results: in October 2011, the Annals of Emergency Medicine produced a report showing a patient-centered care management program reduced annual costs from $1.2M in year 1 to $130,000 in year 2.
Knowing your population — know who is at risk and why
Profiling a patient population — their demographics, payer mix, and complex problems — underpins a proper hospital diversion program. Knowing who the high-risk patients are in a given pool of patients is the make-or-break difference for any Population Health management program.
Examining trends in a clinic’s data to predict which patients will need the most care is no longer an activity to be shunned — indeed, creating models to stratify risk will help identify which patients should have resources allocated to them to help manage their care.
As in all things, but especially with respect to diversion programs, knowing is half the battle. If physicians can tease out which patients are likely to develop complex medical issues, they can better organize their staff to deliver targeted care, eliminating the need for hospital-intervention.
Implementing hospital diversion tactics
Though many of today’s diversion strategies were developed with low-income patients in mind, the same principles may be applied to managing any patient population, regardless of socioeconomic influences.

  • As patients make the transition to “patient-consumers,” they can and should be treated as such. Use your Electronic Medical Record (EMR) as a customer relationship management (CRM) tool. CRMs are used to understand the history and needs of a customer, and your clinical chart can perform the same function.
  • Ensure clinical staff are collecting relevant clinical and social histories so that later you can develop a comprehensive picture of your patient population. Layer on advanced analytics tools to understand monthly trends, and use your EMR’s messaging tools to connect with your patients and keep them engaged with your plan of care.
  • Educate your patients, and reassure them that you can handle their emergent issues — in times of crisis, patients can become emotional and panic, forgetting the advice you’ve given them. In fact, a November 2016 study indicates that fear compels patients to visit emergency departments, despite knowing the costs to their wallet, time, and overall wellbeing. Be intentional about creating a plan for times like this with each of your high-complexity patients — make sure that in stressful situations, the muscle memory you’ve instilled includes a call to your office, first.
  • A holistic approach should be taken with high-risk patients when it comes to diverting them from hospital settings. No less important than a patient’s medical issues is their socioeconomic and potential legal concerns, which have been found to be a predictor of hospital visits. Emergency department frequent flyers often struggle with legal and financial burdens, and soon find themselves in a vicious cycle, as their visits compound these problems, which in turn send them into emotional and physical tailspins. Wrapping social workers, legal aid and behavioral health specialists around these patients can ameliorate their problems, and help them on their road to recovery.

Engage with payers to underwrite your success
Physicians have traditionally had a difficult time seeing a positive return-on-investment for their work managing where, when, and how their patients receive care. A dearth of office resources, and, critically, little to no reimbursement and limited cooperation from payers has historically stymied efforts to adopt these tactics. Tactics implemented by physician groups to divert patients from high-cost settings come at a considerable cost, and continuing down a path without value-based payments is not only discouraging but means these programs will die on the vine.
As healthcare costs rise and pressure profit margins, however, insurers are recognizing that this work is both timely and valuable. Cutting costs and improving outcomes requires a coordinated effort with payers to be successful. More and more, insurance companies recognize that upfront investments in telehealth and care management programs will pay dividends in the end.

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