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'Hotspotting' in healthcare has little to no effect on patient outcomes

About 5% of patients in the U.S. account for half the nation's healthcare costs; the challenge is to reduce their spending.

Jeff Lagasse, Associate Editor

The new healthcare practice of "hotspotting" -- in which providers identify very high-cost patients and attempt to reduce their medical spending while improving care -- has virtually no impact on patient outcomes or readmission rates, according to a new study led by MIT economists.

The finding underscores the challenge of reducing spending on "superutilizers" of healthcare, the roughly 5% of patients in the U.S. who account for half the nation's healthcare costs.

The concept of hotspotting, a little more than a decade old, consists of programs that give at-risk patients sustained contact with doctors, other caregivers, and social service providers in an attempt to prevent rehospitalizations and other intensive, expensive forms of care.

The MIT study was developed in cooperation with the Camden Coalition of Healthcare Providers, which runs one of the nation's best-known hotspotting programs. The researchers conducted a four-year analysis of the program and found that being enrolled in it makes no significant difference to patients' healthcare use.

Significantly, the new study was a randomized, controlled trial, in which two otherwise similar groups of patients in Camden were separated by one large factor: Some were randomly selected to be part of the hotspotting program, and an equal number of randomly selected patients were not. The two groups generated virtually the same results over time.

WHAT'S THE IMPACT

To conduct the study, the MIT-led research team evaluated 800 patients enrolled in the Camden Coalition of Healthcare Providers program from 2014 to 2017. The patients in the study had been hospitalized at least once in the six months prior to admission and had at least two chronic medical conditions, among other healthcare issues. The study was constructed after extensive consultation with the coalition.

Half of the study's 800 patients were placed in a group that used the program's services, and half were in a control group that did not take part in the program. The Camden hotspotting program includes extensive home care visits, coordinated follow-up care, and medical monitoring -- all designed to help stabilize the health of patients after hospitalization. It also helps patients apply for social services and behavioral health programs.

Overall, the 180-day hospital readmission rate was 62.3% for people in the program and 61.7% for people not in the program.

Additional measurements -- such as the number of hospital readmissions for patients, aggregate number of days spent in the hospital, and multiple financial statistics -- also showed very similar outcomes between the two groups.

Findings showed that while the overall number of people in hotspotting programs who need rehospitalization declines over the course of the program, it does not decline by a larger amount than it would if those people were outside the program's reach.

In short, people in hotspotting programs require fewer rehospitalizations because any group of patients currently using a lot of healthcare resources will tend to have lower healthcare use in the future. Previous reports about hotspotting programs had focused on the roughly 40% decline in six-month hospital readmissions -- while not comparing that to the rate for comparable patient groups outside such programs.

THE LARGER TREND

By many estimates, only 5% of U.S. patients are high-need and high-cost, yet they account for about 50% of healthcare spending. 2019 research published in the New England Journal of Medicine finds it's necessary to understand the needs of this patient cohort, identify drivers of their utilization, and implement solutions to improve their clinical outcomes while reducing their costs.

High-need, high-cost patients often have multiple chronic conditions, complex psychosocial needs, and limited ability to perform activities of daily living. Care delivery solutions, including care management, telemedicine, and home health visits, have had mixed levels of success for various outcome measures.

Some of those include system-centric measures such as total cost of services and utilization of secondary care (emergency department use and inpatient hospitalization) as well as patient-centered ones such as self-assessed health status.

A possible explanation for the variable success could be that many solutions are designed primarily by health system administrators, not the patient "customers" who best understand their own needs.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com