New Jersey hospitals reach out to patients to reduce ER visits
Melanie Hightower was what you might call a repeat customer. Her chronic seizures landed her in the emergency room at Jersey City Medical Center on a weekly basis. She’d see a doctor and be handed some medication and sent on her way.
Soon, another seizure, another 911 call, another trip to the ER, another admission to see the neurologist.
Then, about five months ago, the hospital, part of Liberty Health System, set her up with Kenneth King from the medical center’s Wealth from Health program.
King helped Hightower find an epilepsy specialist. When the doctor told her she needed more vitamin D and should eat more dairy, King gave her a list of foods she could buy at the supermarket.
“I haven’t had a seizure in five months,” Hightower said.
That’s great for Hightower, and it’s also good for the hospital, which can free up a bed for another patient and not waste resources in the emergency room on a patient who really shouldn’t be there in the first place.
But the real winners in a story like this are New Jersey’s taxpayers, explained Paul Goldberg, the hospital’s chief financial officer.
Medicaid pays about $6,000 each time Hightower is admitted for treatment of a seizure. It’s hard to calculate an exact figure, but a reasonable estimate is that her meetings with King, which are free, have saved taxpayers about $120,000 over the past five months.
And there are dozens like her in Jersey City, thousands in New Jersey and millions across the nation where 1 percent of the population – these repeat customers – account for 21 percent of the nearly $1.3 trillion Americans spend on health care, according to the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality.
If Hightower’s success can be replicated, it could finally help slow the ever-rising costs of health care that cause private insurance premiums to skyrocket and place a huge financial strain on Medicare and Medicaid.
“If a hospital bills less to society, then the rest of society gains,” said Uwe Reinhardt, a health economics expert and the James Madison professor of political economy at Princeton University’s Woodrow Wilson School.
Hospitals across the state and the country are relying more on data to drive decisions, but only a few are boring down to the patient level to try to prevent emergencies. While teams in places such as Trenton, Camden and Newark are working with small groups of patients – the highest utilizers – Jersey City Medical Center is expanding its efforts to try to reach mid-level users as well.
It is also one of the few hospitals using data to predict where the next emergency will occur. Each and every one of the 90,000 calls that come in, along with their locations and times, are entered into a database called “MARVLIS.” Patterns emerge and the computer can then predict where the next 911 call is most likely to occur.
“It takes all the data and plots it on a map that looks like a weather map,” said Robert Luckritz, director of emergency medical services.
“If you look at the system on a warm summer evening, you’re going to see that it pops up in the areas where there is violent crime because it knows that on a Friday night, there are certain areas of Jersey City where people are going to get hurt.”
On a recent Tuesday morning, a big purple blob hovers over the southern part of Jersey City. The colors are lighter as you move north, indicating there is less of a chance an emergency will occur there. Luckritz can look at the map and strategically place his paramedics in anticipation of the next call.
This reduces response times, which has the potential to save lives. Before the system was implemented, paramedics were able to resuscitate about 20 percent of patients in cardiac arrest. Now, it is closer to 50 percent, Luckritz said. There are also small savings – fewer ambulances need to be on the road and need to drive shorter distances – but the real savings come from the other role paramedics at Jersey City Medical Center are starting to play.
Last year, Luckritz used a system called First Watch to look at the 911 calls received from charity-care patients, those without any health insurance. There were 2,278 patients in this category requiring about 4,600 trips to the hospital. Luckritz drilled deeper. He found the top 50 users were responsible for more than 1,000 of those calls.
“So 2 percent of patients represented 22 percent of transports,” Luckritz said.
Luckritz is working with his staff to try to reach these people before they reach a crisis. It can be a simple knock on the door to check up on a patient, perhaps take their blood pressure or see if they have been taking their medication.
A paramedic who suspects a problem can recommend a visit to a clinic, perhaps saving a trip to the hospital and thousands of dollars in unnecessary, and possibly painful, procedures.
The model for this has received a lot of attention lately. In September, Jeff Brenner, who founded the Camden Coalition of Healthcare Providers in 2003, was awarded the MacArthur Fellowship, known as the “genius” grant. He discovered that in Camden, 1 percent of the population was responsible for 30 percent of the medical costs.
Brenner has spent a decade reaching out to the highest utilizers in the nation’s poorest city and has achieved some startling results. Patients served have seen a 40 percent reduction in emergency room visits and a 56 percent reduction in hospital charges, according to the Robert Wood Johnson Foundation, which funded some of Brenner’s work.
The problem, Brenner said, is that his model is hard to replicate because the country’s health care system is not designed to handle complexities such as alcoholism, drug addiction, mental health problems and other socioeconomic barriers that prevent people from being good stewards of their own health.
“We can pull people back from the brink of death, we can cure cancer, we can transfer hearts and lungs, but we haven’t caught up to those complexities,” he said. “There are so many ways to deliver better health care.”
The same model is employed by the Trenton Health Team – a collaborative effort between the city’s two hospitals, St. Francis Medical Center and Capital Health – which discovered that St. Francis’ most frequent customers were suffering from alcoholism while Capital Health was seeing a plethora of sickle cell patients.
Both of those conditions are better managed outside an emergency room, said Robert Remstein, president of the Trenton Health Team and vice president at Capital Health.
“The emergency room doesn’t manage you like a primary care office,” he said. “They treat you like an episode of illness.”
That means patients are likely to return.
Remstein gave an example of a patient he called “Lady B” to protect her privacy. She was homeless and an alcoholic. In one year, she used the emergency room 400 times, he said. The law requires that each time she walks in she be seen and screened. She was referred to the Trenton Health Team, who helped her find a detox program and a housing program.
Working with 50 of the highest utilizers, the Trenton Health Team was able to reduce ER visits to the city’s two hospitals by about 45 percent and reduce hospital charges for these patients by about 50 percent.
“The system is spending money to provide care that is not effective and not addressing the underlying need,” said Greg Paulson, deputy director of the Trenton Health Team. “The reimbursement model does need to look at the right care at the right time and at shifting funding toward social services because we are not effectively managing care.”
Susan Walsh, medical director for Jersey City Medical Center’s Accountable Care Organization, said their program expands on some of the others in New Jersey by reaching out not only to the highest users but also to mid-level users, offering all patients an incentive to take a more proactive role in their own health management. Patients who remember to fill their prescriptions or have a mammogram earn points that can be redeemed for a gift card.
If you pick up your medicine on time, that might be 10 points, Walsh said.
In the program’s first year, patients who were enrolled saw anywhere from a 13 percent to 34 percent reduction in the number of trips to the emergency room.
What Jersey City’s work reveals is what people such as Brenner have been saying for years – that one of the great burdens on our medical system is the cost of not caring for patients outside the hospital.
“We have a sick-care system not a health care system,” Brenner said. “The way you get promoted, the way your hospital grows and expands is by having more sick people.”
Doctors and hospitals are, for the most part, paid when they see a patient. There is little financial incentive for individual doctors to keep people out of the hospital.
“That’s always been a major problem with American health care,” Reinhardt said. “Very often, to do the right thing, a hospital has to lose money.”
The Affordable Care Act, commonly known as “Obamacare,” tries to incentivize these types of innovative programs. The law authorizes the Centers for Medicare and Medicaid Services to spend $10 billion every decade in perpetuity to fund pilot programs that are supposed to improve payment and service models.
It also reduces Medicare payments to hospitals that have high readmission rates and offers financial incentives for accountable care organizations, which are rewarded for reducing overall costs. That means there is a powerful enticement to shut the revolving door that had patients such as Hightower coming back week after week.
In 2011, Gov. Chris Christie signed a law that allows for Medicaid Accountable Care Organizations, which would pay providers for taking care of a patient rather than treating individual symptoms. Groups such as the Camden Coalition and Trenton Health Team could be reimbursed for keeping people out of the hospital. And if these organizations can demonstrate a reduction in costs, the organizations could share in the savings, helping fund future efforts.
The final rules and regulations for these ACOs are expected to be released by the end of the year.
Even with help from the state, there are plenty of barriers to fixing the system. Some patients refuse help; identifying a problem like alcoholism or drug addiction doesn’t solve it; and income level remains a determining factor in how well people manage their own health.
“But we can solve these things,” Brenner said. “We’re America, for God’s sake. We can figure this out.”
About the Trenton Health Team
Trenton Health Team (THT) is an alliance of the city’s major providers of healthcare services including Capital Health, St. Francis Medical Center, Henry J. Austin Health Center and the city’s Health Department. In collaboration with residents and the city’s active social services network, THT is developing an integrated healthcare delivery system to transform the city’s fragmented primary care system and restore health to the city. THT aims to make Trenton the healthiest city in the state. Support for the Trenton Health Team was provided in part by a grant from The Nicholson Foundation. For more information, visit www.trentonhealthteam.org.