A very small percentage of people use a significant amount of health care in this country. According to one estimate, 5 percent of the people account for 60 percent of health care costs. In California, health officials are busy drawing up a plan to identify these so-called super-utilizers of the Medi-Cal system.
The staff at San Francisco General Hospital has already started looking at these heavy utilizers and is now working extensively with Bertha Swan to help her mother.
"If there's something I need, I can just call them," Bertha Swan tells me. "They help me as far as getting connected to the doctor, doing the email, doing the prescriptions, things like that. So they help me a very lot. Yes they do. They're there for me."
And since starting dialysis in March, her mother has not been to the hospital. "Knock on wood," Swan says.
At San Francisco General Hospital's Adult Medical Clinic, officials estimate just 3 percent of patients account for 35 percent of hospital admissions. And they often come with both multiple chronic conditions and multiple medications.
"They may also be living in a two-bedroom apartment with eight other people," notes clinic medical director Dr. Elizabeth Davis. “They may be depressed, and they may also smoke. And that's a lot to deal with."
And that's why the staff here takes a team approach, using a nurse, a health coach and social workers.
It all starts by building trust with the patients, says Marty Lynch. He's the executive director of LifeLong, a community health organization based in Berkeley. Lynch says it's tough work because many in this population have mental health and substance-use disorder issues.
"These case managers who do this kind of work are saints in my opinion," Lynch says. "They have to have really good persistence and also really good personal skills and the ability to respect anyone with any kind of problem and think positively about them."
Many of the patients, he says, may be homeless. "The second issue is can we get you housed and if we can get you housed, maybe then we can talk you into coming in and seeing our doctor."
LifeLong is working with Alta Bates Summit Hospital to provide coordinated care to frequent utilizers. The new state program will depend on just this kind of collaboration.
Hannah Katch is with California's Department of Health Care Services. She says the proposed Health Home program, along with other proposals, will provide more than just care coordination.
It will "also help the patient get access to supportive housing," Katch says, "or help the patient get access to a mental health provider, or to support groups, or to food assistance.”
The federal government would pay 90 percent of the cost to get this program off the ground. After two years, the Health Homes program will have to cover its costs, Katch says, by making a big dent in hospital admissions and emergency room visits.
But providing more services without spending more money is just one metric. "But really the goal is to try and help these particular high utilizers improve their health," Katch said.
Since more than half of all services are used so inefficiently by so few people, Katch says this is really the prime opportunity in health care.
“That's pretty much the whole ballgame," she says.
Yet a lot of questions remain: Who exactly will be eligible for the Health Homes program? How well will hospitals, specialists and clinics share information? Marty Lynch from LifeLong is curious how much providers will be reimbursed for reaching this difficult population.
“If they want the very toughest people they have to pay a decent rate,” Lynch says.
If approved by federal officials this October, the state hopes to launch the Health Homes programs in seven counties beginning in January. The rollout would expand to other counties starting July 2016.
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