Clinic staff members at Neighborhood HealthSource in Minneapolis were studying patient data not long ago when a number jumped out at them: One of their patients had visited the emergency room 73 times in the previous year.
Alarmed that she might be gravely ill — or running up thousands of dollars in hospital bills — they took a closer look. It turned out she was using a local ER for routine medical care — or simply on days when her regular physician wasn’t scheduled to work.
They met with the patient to explain that she would be better off coming to the clinic. But they never would have spotted the problem in the first place if not for an ambitious new project to improve Minnesota’s massive Medical Assistance program by making front-line medical clinics more responsible for the cost and quality of patient care.
By harnessing a huge database of patient records, Neighborhood HealthSource and nine other safety-net clinics have reduced emergency room use by patients in the experiment by 18 percent. Inpatient hospital use has declined 8 percent, mostly by preventing costly readmissions. As a result, over the past three years the 10 clinics have slowed spending by about 5 percent, saving taxpayers $16.6 million, while also finding new ways to address their patients’ underlying medical problems.
The key is a huge databank of patient claims data that shows where and how 30,000 of their patients are using the health care system.
“For the first time, our [staff members] have a clue about what’s going on with that patient outside our four walls, and then can take necessary interventions to alter that path,” said Steve Knutson, executive director of Neighborhood HealthSource, which has three clinics in north and northeast Minneapolis.
The project is part of a state experiment, called Integrated Health Partnerships, that provides financial incentives to doctors and clinics if they reduce spending for patients on Medical Assistance, the state’s insurance program for the poor. At the same time, the providers must meet quality benchmarks to insure that cost-cutting does not compromise patient care.
“We wanted to test the model that primary care can save the system a tremendous amount of money,” said Deanna Mills, a former safety net clinic executive who now consults with the clinic group.
Since the experiment began, in 2013, Medical Assistance spending has been reduced by an estimated $150 million. Now state officials plan to expand the project to include providers who care for about 500,000 recipients by 2018.
Savings could be sizable: Medical Assistance spends roughly $10 billion annually in Minnesota, counting both state and federal funds, and represents one of the biggest items in the state budget.
Minnesota joins Oregon, Colorado and Vermont in similar efforts to reform health insurance for the poor, known nationally as Medicaid.
In the dark?
In the famously fragmented and expensive American health care system, the projects stand out for having medical providers working together “across the full continuum” of care, said Tricia McGinnis, a vice president at the Center for Health Care Strategies in New Jersey. “In Medicaid, the results have been really positive.”
Under the Minnesota program, each clinic is assigned a certain number of Medical Assistance patients with a history of using that clinic in the past. The clinics take responsibility for coordinating the care of each patient. But they are also, in essence, on the hook for all medical spending that each patient generates — including care outside of their clinic.
At the end of the year, if total spending on behalf of those patients is less than a predetermined target set by state regulators, the clinics become eligible for a reward payment from the state — but only if they also meet quality goals.
But as the patient with 73 ER trips demonstrated, doctors can sometimes be in the dark about visits their patients make to other providers.
If the safety net consortium was to meet and beat its cost targets, it needed better information about those 30,000 patients — most importantly, if they were using high-cost but avoidable hospital and ER care.
The group hired Optum, a subsidiary of Minnetonka-based UnitedHealth Group, to mine the Medical Assistance claims data on its patients and then paint a picture of the health of the population as a whole, as well as health care usage patterns of individuals.
“It is the linchpin … because without that data you are just flying blind,” said Jonathan Watson with the Minnesota Association of Community Health Centers, which is affiliated with the consortium.
At People’s Center Health Services, a clinic in Minneapolis, the Optum data is helping improve care at two levels — the individual patient and “population health.”
After studying the Optum data, the staff found that many parents were using a hospital ER for common childhood illnesses, often when the clinic was closed. As a result, they expanded clinic hours.
They also ramped up behavioral health services after noting high ER use by patients in psychiatric crises. Among the new hires were chaplains who could provide spiritual guidance and help families cope with mental illness.
At the individual patient level, medical director Dr. Steve Vincent and his team at People’s Center learned more about those who use health care services the most. Each week they review a list, generated by a computer, designed to flag those who need follow-up care.
One patient who scored high on the list had been hospitalized for a psychiatric condition but hadn’t visited the clinic for some time. He also was homeless, struggling with addiction and painful abdominal symptoms. They assigned him a psychologist and nurse practitioner to organize his medication review and follow-up visits, and a social worker to address his nonmedical needs.
For patients on Medical Assistance, who often have volatile and difficult lives, solving nonmedical problems can be the key to better health, said Jokho Farah, clinical quality program manager for the People’s Center.
“When you get them connected to someone that can take that burden off them, we can then refocus their energy on their medical needs,” she said. “We’ve seen a tremendous change in the people that are part of this program.”
Reporting for this story was supported by a grant from the Commonwealth Fund through the Association of Health Care Journalists.