Every year, over half of all healthcare expenditures in the US go toward the treatment of just five percent of the population, who are often called “high utilizers." In an op-ed published Sunday by the Mercury News and East Bay Times (the main newspaper for Oakland, and Contra Costa and Alameda Counties), Prevention Institute and Blue Shield of California Foundation make the case that addressing the factors that underlie medical high utilization holds tremendous potential to prevent suffering, improve quality of life, and invest healthcare resources more wisely. A focus on community can have an impact on current high utilizers and those likely to become the next set of high utilizers. Perhaps most of all, it can reduce the pipeline of high utilizers in the long term.
High utilizers frequently use the health system at moments of crisis, through emergency department visits and hospitalizations. They often suffer from preventable chronic diseases – like diabetes, heart disease, or asthma – and/or behavioral health conditions, such as mental illness and substance abuse. Many face steep barriers to regularly accessing needed primary care services, including exposure to trauma, lack of stable housing, insufficient income, and frayed social networks.
The op-ed elaborates:
Consider the experience of a 55-year-old woman who suffers from type 2 diabetes, acute mental health challenges, addiction, isolation, and housing insecurity. This toxic mix creates an adverse interaction, where the whole of the suffering is greater than the sum of its parts. Managing a chronic disease is challenging enough on its own; it becomes dramatically more difficult when one is suffering from post-traumatic stress disorder and is living out of a car. The medical system is poorly equipped to deal with these individuals….The next phase of health system transformation needs to include addressing the community factors that reduce risk for people to become ill or injured in the first place, in tandem with existing innovative efforts to make medical treatment and access more efficient and effective.
The op-ed reflects a new Prevention Institute report, funded by the Blue Shield of California Foundation, that explores how a community-based prevention approach can support better health outcomes, while reducing the need for frequent utilization of high-cost healthcare services and reducing costs over time. Disrupting the Pathway: A Prevention Approach to Medical High Utilization draws on the rich body of prevention research and practice to demonstrate the value prevention brings to existing efforts by the healthcare system.
The report includes model strategies that healthcare organizations and their community partners can implement to address the medical and social needs that have a role in producing high utilization and subsequent costs. Comprehensive community-based approaches address the determinants of health and have the potential to help restore health and reduce the severity of existing health conditions experienced by high utilizers; prevent individuals from becoming high utilizers in the first place; and reduce the overall risk for preventable injury and illness— and improve health— in a community.
This report seeks to catalyze further thinking about the role of community-based prevention in addressing a critical need in the ever-evolving US healthcare system. Download the full report here.