Super-utilizers place huge burden on health care system

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DENVER -- Patients called "super-utilizers” are a little-known class of Medicaid patient who rack up enormous tax-funded medical bills. They repeatedly call for emergency services, even though their health conditions might not warrant such heavy use of the public health system.

Paramedics on the streets of Denver nickname them "frequent fliers" or their "most loyal customers."

Often they are substance abusers or mentally ill. Others use first-responders as taxis to the hospital on a cold night.

By most accounts, 58-year-old Waylan “Mark” Whitney is one of, if not the, top public health customer in Colorado.

Whitney has a history of stabbing himself in the stomach with meat skewers or knives.

His brother, Todd estimates Mark has been to the hospital 40 or 50 times because of his self-mutilation.  The visits have cost several million dollars.

"He usually called the police and fire department and an ambulance to come get him and they take him to the hospital and try to put him back together best they can," Todd Whitney said.  "They've pretty much gotten to the point they don't know what to do for him anymore."

Todd Whitney said his brother was in the hospital or in tax-funded nursing care five or six months last year alone.

The Whitney family said Mark has no medical insurance other than Medicaid, although they believe the federal health care system may have helped pay some of Mark’s bills in the past.

He has also been straining local emergency resources.

Mark Whitney has called 911 so often, most operators don't even have to ask his name. They immediately recognize his voice.

We asked the Colorado Springs 911 center to print out how many separate agencies (police, fire, or paramedics) have had contact with Mark Whitney.

We found there were 85 calls just last year. His name shows up 204 times in the 911 logs in the past three.

His cries for help are as haunting as they are frequent. The following exchange is just one of dozens we heard.

911: "You like to hurt yourself?"
Mark: "I like to open up my belly."
911: "So you've done this before?"
Mark: "Yeah."
911: "A lot, er?"
Mark: "Yeah. Yeah and they know it. It's just a stupid fetish. I just need help with it."
911: "Yeah I think you really do. You could really hurt yourself bad."
Mark: "Ha! I'm cutting my guts open! Yeah"

Mark’s sister, Debra Whitney, says she allowed Mark to live with her for a while, but his devolving mental illness, drinking and medical problems began to scare her.

"We still love him and we still care about him, but we don't know what to do for him,” Debra Whitney said. “He's going to commit suicide. He's going to self-mutilate and he's going to die and if he doesn't die from self-mutilation. He's going to die from exposure to the cold as a homeless person."

Debra Whitney said the family has begged for help. But state and local health services have so far failed.

"We are trying to get him into the state hospital. He really needs to be locked down so he can't drink so he can't stab himself," Todd Whitney said. "Then he needs the mental health part of it too. We've been trying to do that for a long time now."

State health professionals, familiar with Mark Whitney’s case file, refuse to speak on the record regarding the quality or exact cost of Whitney’s care.  They said federal privacy laws prevent it.

However, several agencies, including the Colorado Department of Health Care Policy and Financing, were eager to address the topic of super-utilizers.

Tiny group with an extraordinary cost

Three years ago Colorado launched a special program called the Accountable Care Collaborative. The ACC’s mission was to improve the health of Medicaid patients while lowering costs.

Statisticians began categorizing patients by cost and trying to figure out what caused the high use of medical services.

Some of the top spending Medicaid clients were no mystery.  They were terminally ill cancer patients or patients with severe brain injuries.

However, there was another tiny group that stood out who were labeled super-utilizers.

The state applied two simple criteria to identify them: Patients who visited the emergency room six or more times in a single year; and they were filling 30 or more prescriptions.

Of the approximately 500,000 Colorado Medicaid patients screened so far about one-half of one percent fall into that category. That’s only 3,004 super-utilizing patients statewide.

The group disproportionately cost taxpayers $76 million last year alone or about 6 1/2 percent of the Affordable Care Collaborative $1.2 billion annual budget.

In simpler terms, Chief medical officer of the Department of Health Care Policy, Judy Zersan, says super-utilizers are costing the public health system 30 times more money than the average Medicaid patient.

The average Medicaid patient costs the public health system about $3,000 a year. A super-utilizing client costs close to $90,000 on average.

"We sort of think of the super-utilizers as a population that have very fragmented care. Maybe inefficient. Maybe providers not talking to each other. So our goal is working on coordinating that care,” Zersan said.

She added,  "By addressing that and getting them better care, that helped them with using care more appropriately in the right place, the right time, the right setting."

The program touts the key is pairing super-utilizers with medical case managers. The theory is that orchestrating transportation to a doctor's office, setting appointments to see psychiatrists and honing-in on the correct medications are much cheaper alternatives to emergency room visits.

Last year, the program showed a net savings of approximately $6 million.

Colorado is currently one of only six states chosen by the National Governors Association to participate in a pilot program which will joins forces on an in-depth study of high utilizing Medicaid patients.

As part of that study, the state will reportedly create a spreadsheet of super-utilizers’ names and analyze their costs to the system. The list may be shared with coordinators in each of the seven health care regions in Colorado so area hospitals, doctors and first responders can attempt to coordinate their care in a more efficient way.

Zersan said Colorado has much more to do to prevent certain patients from falling through the cracks, but feels like this state is ahead of many others in identifying the problems.

“We feel confident that our model is a good one - that this is  both saving money, lower costs, but also improving health, which is really our ultimate goal."

The Whitney family said that all sounds good, but they remain reluctant to believe the state is coming to Mark’s rescue. They have decades of disappointment to overcome.

Mark’s 83-year-old dad, Ken Whitney, said, “I think it was pretty apparent they were at a loss as what to do to help him. They really did not offer us a lot of hope being able to give Mark help.”

Mark Whitney is being prevented from speaking about his health care for now.

He's been in the El Paso County jail since last summer awaiting trial on a series of misdemeanor allegations, including DUI and making harassing, repeat phone calls.

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