Socioeconomic, Geographic Factors Play Major Role in Health Care Related Costs

A panel discussing the best approach for readmission prevention programs agreed that socioeconomic and geographic factors play an important role in hospital readmission rates and related costs, and while interventions like community health workers and case managers may help lessen the socioeconomic burdens that result in higher readmissions, providing these amenities is not yet standard. 

“Geographic variations in terms of economic status is a big attribute as to why people are coming back,” Eric Heil, BSE, MBA, chief commercial officer, software solutions, naviHealth, told First Report Managed Care. “They just don’t have a support network—they don’t have the resources when they go back home to be able to get connected.” 

Hospital readmissions are a huge concern for managed care. According to a 2014 study by the Agency for Healthcare Research and Quality, 30-day all-cause hospital readmissions in the United States in 2011 resulted in around $41.3 billion in hospital costs (Hines AL, Barrett ML, Jiang J, Steiner CA. Statistical Brief 172: Condition with the largest number of adult hospital readmission by payer, 2011. Agency for Healthcare Research and Quality. April 2014).  

The panel, held at the World Congress’ 7th Annual Leadership Summit on Hospital Readmissions, discussed prevention programs being used across the country. 

Leslie Zun, MD, MBA, chair, department of emergency medicine, Mount Sinai Hospital in Chicago, advocated for the use of community health workers, who, he said, are not qualified health care providers but rather individuals who are comfortable or trusted in a community. These workers are sent to a patient’s home after discharge and are able to look for triggers or potential issues that may lead to readmission. “You really need to see a home to properly assess what the problems are,” Dr Zun said during the panel.  

The program that Dr Zun spoke of had a focus on patients with asthma and diabetes. Community health workers were able to go to these patient’s home to look for any “triggers”—for patients with asthma, these included if there were any smokers living there, if the home was dusty or needed to be cleaned, and if they had a nebulizer and knew how to use it, and for patients with diabetes, it included when they were testing in their daily lives, what their diet looked like, and what kind of support system they had. 

Overutilization is also an issue compounded by geographic region. 

“Level of care in some places—and again, this is very geographically driven—are overutilizing,” Heil says. 

According to a New England Healthcare Institute study, there is evidence that some procedure rates vary dramatically among different geographic regions, with the cost of variation between high-utilizing and low-utilizing regions close to 30% of total health care spending (Deluane J, Everett W. Waste and inefficiency in the U.S. health care system. New England Healthcare Institute. February 2008).  The New England Healthcare Institute attributes this, in part, to the limited adoption of information technology, especially in areas of decision support and care coordination. 

Finding the balance that’s optimal for the case mix in a specific geographic region is difficult according to Heil, but “payers and providers are all focused on really matching that kind of intervention level with patient needs.”

Heil said that companies like naviHealth can help “bridge that gap both with data, and with actual referral management connections, so that messages and documents and records can all be transitioned from setting to setting while also supporting that longitudinal view.”

“Case mix and socioeconomics—it’s a local phenomenon,” Heil said. “Its like Amazon or Netflix, the more you do it, the better it knows what to recommend to you next, its the same kind of analogy as those factors and ultimately being driven to then inform the next decision.”

While hospitals and organizations are looking at innovative ways to reduce readmission among those in high-risk socioeconomic areas, the government and Centers for Medicare & Medicaid Services(CMS) are starting to get in on the action too. 

“The CMS Innovations grant that they announced around Accountable Health Communities [AHC] is all geared toward getting providers and payers to ultimately engage this network of social services,” Heil said. 

The AHC model, according to the CMS website (www.innovation.cms.gov), addresses the gap between clinical care and community services and tests “whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care.”

 This 3-track model, implemented over a 5-year period, will focus on: (1) increasing patient awareness of available community services, (2) assisting high-risk beneficiaries in accessing services, and (3) encouraging partner alignment so community services are available.  

Forty-four cooperative agreements will be awarded to applicants who will partner with state Medicaid agencies, clinical delivery sites, and community service providers. Cooperative agreement awards should be announced in the fall of 2016.—Kelsey Moroz