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Making a Business Case for Care Coordination of Uninsured Patients

The Problem:
While hospitals are incentivized to reduce 30-day readmissions by CMS in an effort to lower payments to IPPS hospitals with excessive numbers, the cost of additional staff and services to do so, along with the perceived loss of patient visits, has often appeared to be a financial impediment to hospitals committing to care transitions services in the long term.

The Goal:
Demonstrate that programs like AccessHealth and the SC Healthy Outcomes Plan can be both beneficial to the patient and make financial sense to hospitals.

Method & Implementation:
McLeod AccessHealth Pee Dee Director Jason Cooke knew he needed to make a business case for the work that his network and the Healthy Outcomes Plan (HOP) were doing to assist the chronically ill, uninsured, high Emergency Department (ED) utilizers in his region. By improving the coordination of care for the uninsured, the thinking goes, we can improve health, lower healthcare costs and sustain a better system of care than the current model. The HOP supports hospitals looking for these alternative models and can, like AccessHealth networks, often give patients temporary medical homes that can facilitate ongoing access to a primary care team to address preventive, dental and behavioral care. By tailoring to the specific individual needs of patients, these efforts can improve the overall utilization of healthcare services.

Because both AccessHealth and HOP received initial outside funding, a sustainable, financially-sound case needs to be made to hospitals to continue these efforts.

Cooke found that by pulling the last 18 months of data for each patient participating in the HOP program, the finance staff could calculate the total charges associated with that patient’s care and determine an average cost per visit.

“Then, if we added them to AccessHealth or HOP, we could re-run the report on the patient and compare the data,” Cooke explains. “Finance could then attach another cost-analysis to the patient in the program.”

Even given what Cooke calls “a lack of concreteness” to the numbers, the results of the exercise were stark. Among patients enrolled in HOP, ED utilizations decreased by about 28 percent while in-patient stays went down 34 percent.

The key says Cooke is having the patients cycle out of the program in a timely fashion.

“We have a lot of data we’ve been able to collect over the years, and the average stay is 18 to 24 months,” he added. “Usually at that point in time, we have found them a way to obtain insurance, whether it’s Medicaid or a job with benefits. Or they move or pass away or something [else] happens.

“A lot of these people have never paid a hospital bill,” Cooke said. “These are not the people who can pay $30 dollars a month. The hospital was eating [those] costs.”

Cook projected the savings at about $2.3 million dollars, and he was able to go to the hospital’s administration and eventually the Chief Executive Officer and the Board to make a case for the program.

Thanks to Cooke’s dedication and data collection, McLeod Health is committed to supporting AccessHealth Pee Dee in the future to both improve the health of their patients and reduce Emergency Department utilization in the system.