Madison, WI
Barb Simons, RN
Cate Ranheim, MD
October 2010
Overview:
1.The Need
2.The Program
3.The Patients
4.The Analysis
Defining the Needs for a Solution:
• PATIENTS: ED is not the right care for increasing
chronic care management needs
• CLINICIANS: under or over-treating ED patients
• PAYORS: insurance premiums rise in response to
hospitals increasing costs to cover bad debt and
uncompensated care
• HOSPITAL: capacity constraints in ED require
targeting avoidable ED admissions
– we began with those who, upon intake, stated
homelessness, provided shelter addresses, or did not give
an address
Overcoming Barriers to Good Health in
the Medically Underserved
• Retrospective, medical record review
• 330 homeless and unstably housed patients in MADISON, WI
seen in ED or hospitalized at Meriter Hospital between 1/0710/08
• manually reviewed to identify and evaluate barriers to good
health:
-Housing
-Literacy
-Lack of primary care provider
-Transportation
-AODA
-Medications
-Mental Illness
- Insurance
Where Should We Focus Our Resources?
Housing
Lack of primary care provider
AODA*
Mental Illness*
Medications
Insurance
*Each identified in 15% of population
Literacy
Transportation
HEALTH Patients Meriter Medical Record
Numbers
Program patients sought Meriter emergency services 138
times in the 10 months before the program started.
Over $86K COST savings potential from these visits
alone*.
*Based on Medicaid reimbursement for ED visits of $0.13/$1.00 charge
November 2009
Helping Educate and Link the Homeless
(HEALTH) Program is born:
• Four outreach locations open in an
effort to overcome identified barriers to
good health
• One outreach clinic/week, four
alternating sites, volunteer-staffed
• Funded with $250,000 grant from
Meriter Foundation for 2010
The “Hut”
HEALTH Program Timeline
HEALTH Program
HEALTH Hut Opens
Mar 2010
HEALTH
Full-time RN Starts
Feb 2010
HEALTH Program
Four Mobile Sites
Open
Nov 2009
Overcoming
Barriers in the
Medically
Underserved
Project
Jan-Nov 2009
Five Mobile Sites
Daily Hut Visits
Jul 2010-Present
HEALTH Program Logistics
LOCATION
STAFF
“Hut”
1 FTE RN
Mobile
clinics
5-8
volunteers;
MD, NP, RN,
SW, Admin
HOURS
CARE
40+ hrs/week Follow-up to
mobile sites,
receive
referrals
3 hours/week Identify and
per team
treat patient
medical needs
HEALTH Volunteers
Facility, 22
n=75
HEALTH Volunteer Hours
Jan-Sept 2010
~ 718 hours
HEALTH Volunteer Hours (Estimated Value)
Jan-Sept 2010
~ $25,000*
* Madison market -based
HEALTH Program Donations
Dollar Value
25000
20000
15000
10000
5000
0
HEALTH Hut*
Value
Number of Donors
HEALTH Hut*
7,300
$1,300
17+
Medical
Supplies
Office
Equipment
Medical Supplies
$20,730
13
Office Equipment
$11,230
5
*Direct expenses only: value of HEALTH Hut building or utilities not included
**Time frame = 6 months
The Patients
n=185
HEALTH Patients
Housing Status
HEALTH Patients
Payer Status
/No Coverage
HEALTH Program Data
Program patients Nov 2009 – Aug 2010
185 unique patients
393 visits
PRIMARY DIAGNOSIS CATEGORY:
CardioRespiratory
36%
1% unknown
Endocrine
2%
Other
15%
Mental
Illness
21%
MusculoSkeletal
17%
Infection
9%
HEALTH Patients
Medical Diagnoses by Bucket
• Most cardiorespiratory patients have a secondary
cardiorespiratory diagnosis
• Mental Illness: secondary diagnosis prevalence is
only 2% higher than primary diagnosis prevalence
Secondary Diagnosis Group
Primary Diagnosis Group
BucketOne
Cardiorespiratory
Infection
Mental Illness
Musculoskeletal
Other
Grand Total
TOTAL SECONDARY GROUP
Cardiorespiratory Infection Mental Illness Musculoskeletal Other N/A
Grand Total
27
5
9
9
11
5
66
5
3
3
1
2
3
17
8
1
10
7
10
2
38
5
1
8
7
7
3
31
3
3
3
10
8
27
48
10
34
27
42
24
185
25.9%
5.4%
18.4%
14.6% 22.7% 13.0%
TOTAL
PRIM ARY
GROUP
35.7%
9.2%
20.5%
16.8%
14.6%
HEALTH Patients
Co-morbidities
n=185
HEALTH Patients
Number of “Hut” Visits per Patient
Total Visits: 393
The Analysis
HEALTH Patient Patterns
• Top 5 diagnoses represent just 22% of all diagnoses:
Hypertension, Depression, Anxiety, Type II Diabetes
• Transitionally-housed patients made more repeat visits to
the Hut per person, on average, than those reported as
homeless or permanently housed.
Patient Pathways
% of
Patients
Incurred Costs
Avoided Costs
A
B
C
41%
Program
ED visit
55%
Program x X visits
ED x program visits
D
E
F
G
0.5%
H
3%
< .05%
Program + ED
Program + ED + IP
None, plus program-sponsored
care
ED
Additional ED visits
ED visit
None
ED visit + I/P
None
Multiple ED + I/P
None
Value: avoiding unnecessary ED visits, reducing
need for I/P admissions
Where do the underserved go for care?
Control Group
F
ED
C, D
E
ED
H
HEALTH Program Participants
A, B
G
D
E
I/P
I/P
Before
After
Measuring Value
Estimating What Would Have Happened …
The estimated likelihood of a substitute ED visit …
times the median ED cost per Medicaid patient …
plus the estimated likelihood of an inpatient admission
times the median cost of a Medicaid I/P admit
times Elixhauser co-morbidity weight
…minus What Did Happen
The cost of care provided at the Hut…
and any ED visit incurred
times the median cost of a Medicaid ED visit
and any I/P visit incurred
times Elixhauser co-morbidity weight
[Probability of ED admit x Median ED Visit Cost + (Probability of I/P Admit x Median Cost of I/P Admit) x
(Elixhauser Index Value)] – [(N hut visits x Median Hut Costs of Care per Patient +(ED Visits Incurred x
Median ED Visit Cost ) + ( I/P Admit x Median I/P Cost* Elixhauser Index Value)]
How It Works
What Would Have Happened: Potential Savings for Avoided Costs of Care Minus What Did Happen: Costs of Care Provided*
Probability
of ED
admission
w ithout
MRN
Patient Name
Program
402330 Homer Simpson
0.8
300315 Moe Syzlack
0.7
108567 Selma Bouvier
671958 Joe Quimby
0.4
1
Probability
of I/P admit
w ithout
Program
0.7
0
Average ED
Visit Cost
$ 300.88
$ 300.88
0.2 $
1 $
Patient
Average Elixhauser
Diagnosis
I/P Cost Index
Category
(by unit)** Score
Cardiac/Respiratory10,000
$
1.48
Cardiac/Respiratory10,000
$
1.17
300.88 Cardiac/Respiratory10,000
$
300.88 Cardiac/Respiratory10,000
$
1.19
1.06
-
Projected Savings
Hut Care
Costs: Visits
x Fixed
ED Visit
Elixhauser
Median Cost Incurred I/P Visit Index
of $50
(1 or 0)
Incurred Score
1
1
0
1.48
2
0
0
1.17
1
1
0
1
0
1
$10,250
$111
1.19
1.06
$2,450
($50)
$12,761
*Retrospective EPIC review up to 30 days from first visit
** Costs are relative to unit average cost per case
Costs = total direct expenses only (salaries, supplies, bus passes, equipment) and excludes
building depreciation, overhead, etc.
Average Inpatient cost of care is specific to diagnosis bucket (i.e., Service Line)
The greater the ALOS and Median Inpatient Cost of Care the greater the avoided cost
opportunity: analyze your current volumes to estimate your potential savings
*all patient and cost data listed here is fictitious
Quick and Dirty ROI Recipe
1. Gather ingredients from Finance Department:
–
–
–
Cost per Medicaid ED visit: (total direct costs *Medicaid % payor mix)/N Medicaid
patients
Number of ED admits from either local shelters or no address in one year: assess
common ED diagnoses by service line
Average I/P costs = total direct expenses for Service Line/N patients (use 1 year of
data at least)
2. Calculate your current costs for these patients to date using
the above data
3. Use the formula presented to determine your cost reduction
potential
•
•
•
4.
Sample at least 30 patients: estimate probability of ED avoidance through record review
Use Elixhauser comorbidity values (see supplemental)
Assume a indigent care program estimated cost per patient: we used $50
If the cost of program startup – donations is less than #3,
consider implementing an off-site indigent care program like
HEALTH.
Thank you to our donors!
www.healthprogram.us
Meriter Foundation
St. Vincent de Paul
UCC-Memorial Church
Meriter Hospital
Masimo Corporation
Association of Spiritual Caregivers
Wisconsin Medical Project
Dr. Bernie Micke
Dr. Jack Kenney
Nicole Heide, RN
Mandy McGowan, RN
McGovern & Sons
Jo Hoffman/Ellen Boyce
John Warden
Home Depot
Hometown Flooring
Sherwin-Williams
Meriter Medical Staff Office
www.healthprogram.us
A special thank
you to our friends
and colleagues,
Heidi Kimble and
Melissa Strayer,
for data analysis
and volunteer
time!
SUPPLEMENTALS
Supplemental A: Slide 4 Calculations
N
2009 Total Inpatient Discharges
Estimated Medicaid and Self Pay Discharges
Exected I/P admissions
Total Gross Charges, 2009 I/P, all Payors
Medicaid and Self Pay % of Mix
Medicaid and Self Pay Total 2009 Gross I/P Charges
Minus Medicaid Reimbursement
Discount
Discount/Discharge
Total Direct Expense: I/P, all payors
Total Discharges 2009, all payors
Average Direct Expense/Discharge
Medicaid Reimbursement
Shortfall per I/P MedicaidDischarge
2009 Program patient shortfall
Avoided ED Costs of Program Patients Jan - Oct 2009
Potential Savings Opportunity*
* before Program expense consideration
%
21556
3233
$
$
$
$
$
$
$
$
$
$
$
15%
35.38461538 3.98 ED visits per patient admit in 2009, all payors times
$
138 visits by HEALTH program patients before program
519,024,049
15%
77,853,607
19,463,402
58,390,206
2,709
147,062,854
21556
6,822.36
1,705.59
5,116.77
60,352
25,617
85,969
Supplemental B: Elixhauser Comorbidity Index
Source: Effects of Specific Comorbidities on Outcomes Controlling for Demographic, Insurance,
and Other Clinical Factors of Adult, Nonmaternal Patients Who Were Hospitalized in California
in 1992 (n = 1,779,167)
Elixhauser, Anne; Steiner, Claudia; MD, MPH; Harris, D; Coffey, Rosanna. Comorbidity Measures for Use with Administrative Data.
Medical Care. 36(1):8-27, January 1998.