Ruby Gallegos knows she is high maintenance.
She got used to dropping into emergency rooms for migraines.
A nurse holds her hand during blood-pressure checks to help control the doctor-office anxiety that artificially spikes her readings.
Gallegos, 42, suspects the origins of all pills. She asks her teenage son to swallow a Tylenol from the bottle before she does.
Her panic attacks are getting better on shopping trips, but only in a relative sense: She can now shop alone in a crowded grocery store for 15 minutes while her husband waits in the car, a mark of progress from when he had to be within three aisles.
Gallegos’ mental health issues, intertwined with high blood pressure, bowel trouble and obesity, make her a very expensive patient for the state of Colorado. As a high-risk Medicaid user, Gallegos personifies one of the maddeningly irreducible statistics of health care costs: The sickest 1 percent of patients spend nearly 30 percent of a health system’s money.
The pattern holds true even in private insurance systems. A recent compilation by the national benefits firm Milliman confirmed that ratio and its startling counterpart: The healthiest 90 percent of a system’s patients cost only slightly more to treat than that ill 1 percent.
With hundreds of thousands more Coloradans joining Medicaid under health care reform in the next three years, and millions nationwide, the race is on to find and treat these high-cost patients before they arrive at emergency rooms and swamp the system.
“The savings are huge” even if Medicaid reached out to even half of the sickest patients before they need urgent, expensive care, said Sai Moturu, a researcher who studied how Arizona could use high- powered computing to identify high-cost Medicaid patients.
High-cost patients
Colorado hosts a number of pilot programs and modeling experiments targeting high-cost patients. One such effort uses sophisticated mapping of neighborhoods, to learn why, say, an elderly resident would rather call an ambulance than have a neighbor drive her to a preventive appointment.
Software can sift through tens of thousands of medical records to identify, for example, every shut-in diabetic in Denver who is on antidepressants but hasn’t seen a doctor for six months.
And sometimes attacking the high-cost problem combines the high tech with more hand-holding.
Denver Health sends taxis to pick up reclusive patients — and still those patients may wander away between the door of the cab and the door of the clinic. A case worker will walk them from the taxi into the appointment.
Kaiser Colorado’s work helping an elderly patient sort out prescriptions is no good if the patient can’t read labels — so a case “navigator” will find money for new eyeglasses.
The shock from one state pilot program in high-cost patients was that solutions didn’t begin with a medical exam, but with groceries, transportation, utilities and filling long-neglected prescriptions.
“You think it’s a minor problem, but it’s a much more serious problem than you ever imagined,” said Dr. Susan Pharo, director of a Kaiser pilot with about 1,500 Medicaid patients. “If you have no food at home, how can you work on the diabetes? Unless you can work on those issues, how can you work on the underlying disease?”
Attacking the problem
Pharo’s program is one of two pilots launched by Colorado’s Medicaid office to attack the high-cost patient problem. Kaiser contracted with the state to take on high-risk Medicaid patients in Denver and Jefferson County. Kaiser gets fees for each health service given to patients, plus a $20 per-member, per-month fee to manage overall care.
Kaiser assigns the high-risk patients to case managers such as Deb Becker, who had Gallegos in her portfolio of 108 clients. Doctors assigned to the Kaiser patients agree to longer appointments and instant access from needier patients.
“She always listens to me,” Gallegos said of Dr. Julie Cohen. “Many doctors have not been patient with me.”
When Becker learned that appointments, blood-pressure cuffs and pills set off Gallegos’ anxiety, she helped her build a “self-soothing kit” for appointments. Touching the baby sock in the kit calms Gallegos down.
Becker shares medical results with the Jefferson County Mental Health professionals who treat Gallegos’ anxiety.
Gallegos’ doctors wanted her to lose weight, but Gallegos didn’t have the money to join a gym, so Becker helped her enroll in a weight-management program.
“Finally, people are seeing that health depends on a lot more than your actual medical services,” said Dr. Jane Brock, medical officer of the Colorado Foundation for Medical Care, which contracts with Medicare to track quality and costs in the federal program.
“Coaching” the elderly
Brock’s group has found preventing quick readmissions after initial hospital stays to be one of the most reliable ways of cutting spending. A northwest Denver pilot program providing “coaching” to elderly patients leaving the hospital cut 30-day readmissions by nearly 10 percent, and Medicare has expanded the program nationwide.
Brock is among those pushing to use the huge volumes of Medicare statistics to map out high-risk patients.
One northwest Denver ZIP code in the readmission pilot stood out with high rates of elderly residents returning to the hospital. Overlaying census data for the neighborhood shows an area in transition, with new Latino families moving in and white homeowners aging in place.
Brock said further research could explore whether aging homeowners have few connections to their new neighbors and don’t seek help with rides to the drugstore, grocery store or doctor.
Left to themselves, the elderly homeowners weren’t taking care of their illness and were suffering costly emergency-room visits or hospital readmissions.
Brock envisions other mapping uses, as police departments have done in targeting crime-ridden blocks: Medicare records might show homeless dialysis patients taking ambulance trips from one area, perhaps a bridge they sleep under or a shelter they frequent. A health team could coordinate better — and cheaper — transportation to dialysis centers and regular appointments.
“Maps are actionable,” Brock likes to say.
Measurable results may still prove elusive, no matter how useful the maps or statistical modeling.
Chronic diagnoses and mental illness are stubborn medical facts. Colorado Medicaid officials say a contractor, MDRC, is still seeking conclusive answers from three years of pilot results.
National analysts say various high-risk programs have had some success in limiting urgent care. But some of the pilots are also finding higher upfront costs than they expected.
Costly extra services
The extra services — taxi rides, long interviews with primary-care doctors, more tests and screenings — turn out to be costly. An unfilled prescription is, after all, money saved for the short term.
“It takes time to change chronic diseases,” said Dr. Judy Zerzan, medical director for Colorado’s Medicaid program.
And some patients are ill whether they get extra help or not.
“It turns out they’re being hospitalized a lot because they’re really sick — they actually need to be getting a lot of health care,” said Charles Michalopolous, an MDRC fellow and health analyst.
Gallegos believes she is costing the system less than she used to. She no longer flees to an emergency room for a bad headache. Stress tests showed her chest pains came from anxiety, not a bad heart.
So Gallegos is trying to exercise, alter her diet, take her medications on time and call Becker if she panics. Her to-do list has gradually expanded beyond “not dying.” The focus now is finishing enough paintings to show in a Jefferson County summer exhibit.
“My only goal,” she said, “is to not feel anxious every day.”
Michael Booth: 303-954-1686 or mbooth@denverpost.com
