Targeting and Healing Medi-Cal's Most Expensive Patients -- And Saving Money

Donald Meade, 52, at his apartment in Fullerton. Meade has battled addiction, cancer and chronic heart problems that fueled recurring visits to the emergency room. Now he's in a 'housing-first' program. (Heidi de Marco/KHN)

SANTA FE SPRINGS -- Don Meade may not like hospitals, but he uses them. In just one year, he made 62 trips to the emergency room. He rattles off the names of local hospitals in Orange and Los Angeles counties like they're a handful of pills.

"St. Joseph's, Laguna Hills," he says. "The best one for me around here is PIH in Whittier."

At 52, Meade has chronic heart disease and other serious ailments, and he is recovering from a longtime addiction to crack cocaine. Today, he lives with his dog Scrappy in a small apartment in Fullerton.

As health care costs continue to rise, attention has turned to a tiny number of expensive patients like Meade, called super-utilizers. One program in Southern California has taken a different approach to treating Meade and other high-cost patients: Over the past two years, it has tracked them, healed them and saved a ton of money along the way.

Beyond making a trip to the ER pretty much every week of the year, Meade has had innumerable X-rays, scans, tests and hospital admissions — all of it on the taxpayers' and hospitals' dime, since he is a beneficiary of Medi-Cal, the state and federal program for the poor.

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"The doctors and a few nurses knew me [by name], and I told them I should get some stock in the hospital because I was there so much," he muses.

Meade received more than $1 million in care each year in the two years before he entered the Orange County program, according to Paul León, CEO of the Illumination Foundation, which runs the Chronic Care Plus program that has stabilized Meade and found him housing.

"It's crazy," says Maria Raven, an associate professor at UC San Francisco who specializes in frequent-user policy. "This small group of people makes quite an impact on the health care system, and on the finances of the health care system."

Within Medi-Cal, frequent health care users make up just 1 percent of the patient population, but soak up about one-fourth of health care spending, according to Dr. Kenneth Kizer at the Institute for Population Health Improvement at UC Davis.

That's why health professionals across California have started targeting this problem group.

Donald Meade plays with his puppy, Scrappy, at his new apartment in Fullerton, Calif.
Donald Meade plays with his puppy, Scrappy, at his new apartment in Fullerton, California. (Heidi de Marco/KHN)

In a small, busy room in a facility in Santa Fe Springs, just up Interstate 5 from Disneyland, the Chronic Care Plus program's lead nurse, John Simmons, directs care for a select group of homeless frequent users.

Simmons says the big secret about these health care frequent fliers is that they're not necessarily the sickest patients -- they're often just homeless, with substance abuse or mental health issues, and they routinely end up in the emergency room.

"It was them relying on the ER for everything," Simmons says. "They got a common cold, they’d want to run to the ER."

To break the cycle, Simmons does what is known as intensive care coordination. He helps the 37 participants, including Don Meade, find housing, get off drugs, get access to services and make an appointment with a primary care doctor.

The Illumination Foundation, a homeless health services group based in Orange County, started the program with the goal of breaking the vicious cycle into which these people had fallen, and then following them over a two-year period. That length of time, Simmons says, can change their lives for good.

"The beauty of the program was, we took those people and got them self-sufficient," Simmons says, "and you notice their health [go] on an upward trend."

The program saved $14 million in health care spending for just those 37 people over two years, compared with the two years prior to the launch of the program.

That doesn't count the savings of requiring fewer police and emergency transportation services, Simmons says.

Saving so much money with so few participants is an open invitation to expand the program, says Pat Brydges, an administrator at St. Joseph's Hospital, which helped fund the program.

"There are homeless people in every city in every state," Brydges says. "There's no reason why this wouldn't work across the nation."

It is consistent with St. Joseph's mission to help all people, and the cost savings is an extra perk, she says.

She pauses briefly to contemplate how much money would be saved if this tiny pilot program went national.

"Wow, I don’t even know if I could count that much," Brydges says. "But if we can do $14 million in this one area alone, it’s amazing what we could do across the nation."

Back in his Fullerton apartment, Meade says he now sees a primary care doctor instead of going to the emergency department. His weekly trips to the hospital have decreased, though he still has ongoing heart and health problems.

Being followed by program coordinators over such a long time has really made a difference in his life, Meade says.

"A lot of the stress leaves after you’re in your own home, but if you're out in the street you’re worried so much all the time," he says.

Getting off the street is one thing, Meade says, but staying off the street is another. It's not just that he has his own doctor now, and better health. He has a new life, he says.

The Illumination Foundation plans to release data at the end of June on its first two years.