Targeting ‘Super-Utilizers’ with In-Home Care May Not Curb Health Care Spending

One method using in-home care that inspired hope in reducing health care spending may not be effective after all. Tending more to “super-utilizers” did not reduce hospital readmissions, according to a new study from The New England Journal of Medicine.

Super-utilizers are the 5% of the patient population that make up half of the nation’s total health care spending. For years, health care providers have tried to better serve this targeted population to reduce their trips to the hospital and emergency rooms, in turn lowering overall health care spending.

A seemingly effective program developed out of Camden, New Jersey, was built on the idea of “hotspotting,” a process that used teams of nurses, social workers and community health workers to visit and keep tabs on high-risk patients to avoid rehospitalization. The Camden program was ostensibly successful in observational studies around the country, and, thus, given funds to expand.


The program won so much acclaim, in fact, that well-known health care thought leader Atul Gawande — author of “Being Mortal” — wrote about it in The New Yorker. But the hotspotting program may be flawed.

As part of the New England Journal of Medicine study, 800 participants were defined as people with “medically and socially complex conditions.” Participants also had at least one hospital visit within the last six months.

This group that received extra attention in the home and via telephone after being discharged — the hotspotters, so to speak — ultimately had a 62.3% admission rate.


A control group that went without the extra attention, in comparison, had a 61.7% readmission rate.

Overall, the group of 800 averaged 1.8 hospital admissions over the prior six months. For reference, the Camden population average was just 0.1 per person over that same time period.

The main takeaway of The New England Journal of Medicine study: Targeting super-utilizers as a means to reduce the total cost of health care spending is not as viable as previously thought.

The program in question was piloted by the Camden Coalition of Healthcare Providers.

“Regression to the mean — the tendency for patients selected for the exceptionally high cost of their care at a moment in time to move closer to average cost over time — may bias observational studies of super-utilizer programs toward spurious results,” study authors wrote.

Despite its skepticism, the study does not undermine the value of having eyes and ears in patients’ homes after discharge in general, nor does it assert that there’s no way to reduce super-utilizers’ cost of care. In this case, however, the wealth of resources dedicated to these high-risk patients was still not enough to curb their chances of being readmitted to the hospital.

“The results suggest both the challenges of reducing readmissions in a medically and socially complex super-utilizer population and the importance of conducting randomized evaluation of interventions such as this one, which, because they target high-cost patients, are likely to show substantial regression to the mean in observational studies,” the authors noted.

Apart from preventing avoidable trips to the hospital and ER, many believe the key to lowering health care spending is simply using health care dollars more effectively.

About a quarter of all U.S. health care spending — $760 billion to $935 billion per year — can be categorized as waste, a 2019 study from Humana Inc. (NYSE: HUM) and the University of Pittsburgh School of Medicine found.

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