Rebuilding lives to reduce ER use
Innovative attempt to help some frequent users change their lives holds promise — and faces challenges
The pitchman for San Diego’s effort to reverse the cycle of 911 calls from the city’s homeless enclaves makes no apologies for his fiscal-first approach.
Brian Maienschein, commissioner for United Way’s plan to end chronic homelessness, and prospective state assembly candidate, explains: “I’m the only guy in America working on homelessness with a picture of Ronald Reagan on my office wall.”
“The old way wasn’t working,” added Maienschein, a Republican and fiscal conservative. “In an era of declining government resources, it is more important than ever to be able to show the long-term results actually save money.”
Maienschein’s “new way” is Project 25, a program in its second year that targets the city’s most expensive frequent users of 911 for permanent housing and ongoing medical care, all at a fraction of the cost of leaving them on the street. City officials estimate that less than 1 percent of the city population — 1,136 frequent users — will account for more than 17 percent of San Diego’s ambulance and paramedic calls in a year. That’s more than $20 million.
The program’s institutional core would make liberals happy: federally funded housing vouchers, a Medi-Cal health plan, complete with mental health services, are among the assistance offered to clients found by homeless outreach workers.
The program, which formally opened bidding for social services partners in August 2010, ended up with 36 clients instead of the 25 originally sought. No longer would those homeless men and women be driven to use 911 as health plan and shelter.
With his preliminary data for Project 25 projecting first-year savings of $5.3 million, Maienschein could end up pleasing conservatives and stumping liberal critics, who found him an inexperienced choice for local homeless czar.
According to program estimates yet to be reviewed by an independent auditor, the most expensive frequent user in Project 25 slashed his medical and public services bill from $455,521 in 2010 to $51,882 in the first six months of 2011. The least expensive cut costs from $57,299 in 2010 to $0 after Project 25 enrollment, according to the figures.
However, Maienschein’s marriage of conservative cost-cutting and liberal social good competes with a powerful incentive for hospitals to continue providing a merry-go-round of care.
Hospitals receive more than $11 billion in federal Medicaid funding annually to care for low-income and uninsured patients, including frequent users. The money comes from what are called Disproportionate Share Hospital payments, or DSH funds, meant to offset the costs of treating such patients. Instead, critics say, they have evolved into a precious funding stream.
“It’s the difference between losing money and making money,” said Gerald Kominski, director of the UCLA Center for Health Policy Research, who believes the disproportionate share system has financially rewarded hospitals to provide repeat care.
Nevertheless, Maienschein, working with 22 city, county and nonprofit entities wants to expand the program to hundreds of San Diego’s needy — using savings to taxpayers as his mantra. The plan includes an ace in the hole: cooperation with Dr. James Dunford, the city medical director in charge of Emergency Medical Services, who wants to use real-time, electronic 911 records to initiate future project enrollment.
Dunford, who sits on a U.S. Department of Health and Human Services board debating new ways to care for low-income, high-need patients, wants to push for federal funding to be granted when a hospital reduces a patient’s cycle of frequent use.
“There is a huge ball of money with none of it being spent on fixing the problem,” Dunford said. “Hospitals are being reimbursed for the consequences of a broken machine.”
The National Association of Public Hospitals and Health Systems, which represents safety net hospitals receiving Disproportionate Share Hospital funds, believes the time could be ripe for a vision like Dunford’s to take hold. Because the health reform bill passed in 2010 would provide coverage to an estimated 32 million Americans who were previously uninsured, the industry expects DSH payments to be reduced to $1.8 billion by 2017.
If major provisions of health reform withstand a Supreme Court review that began last month, DSH funding will be made largely obsolete by a multibillion-dollar expansion in Medicaid funding, which is called Medi-Cal in California. A NAPH representative said frequent use is such a costly cycle that the organization generally supports its reduction.
“The financial incentive to encourage frequent use is just not there,” said Xiaoyi Huang, assistant vice president for policy at the NAPH. She pointed out, “Not all of the contributing factors [of frequent use] are medical, nor will these underlying causes go away based solely on the actions of the hospitals.”
Maienschein says if hospitals, housing programs and first responders work together to tackle frequent use, millions in savings could be funneled back to San Diego to address mounting general fund needs.
“Streets, police officers, firefighters, fire trucks, potholes, streetlights, increased library hours — the list goes on and on,” Maienschein said.
But before Project 25 can fill potholes and keep large numbers of the needy off the streets, Maienschein will have to tackle what experts from similar programs around the country call a litany of program challenges.
So far, he is struggling with a reliable estimate of taxpayer savings.
The savings projections for Project 25 did not include the cost of providing services — from housing vouchers to particularly expensive mental health sessions — to seven of its 36 clients. The program also used averages — like the typical cost of an emergency room visit — instead of the actual bill rung up by that client. Maienschein said he is negotiating with area hospitals to get the actual bills.
Maienschein believes the final savings tally will end up larger than his preliminary estimates, which he called “conservative.” The estimates already show an 83 percent reduction in costs for Project 25 clients.
“The figures will end up being more impressive,” Maienschein said.
Maienschein might be too optimistic, if the experiences of three decades of frequent user programs, from the longest running in Seattle to a more recent effort in Los Angeles, are accurate predictors.
No matter how the math was done, savings downshifted over time, directors of those programs said.
“It’s a model that produces diminishing returns. That’s just an intractable feature,” said Bill Hobson, executive director of Seattle’s Downtown Emergency Service Center, which in 1979 became the first program in the country seeking to address frequent use.
Hobson, and all program directors interviewed for this story, emphasized that San Diego’s effort should be applauded and refined over time as it joins a national movement to address the human and financial toll taken by frequent use.
Experts say there is no national estimate for what frequent users cost the public each year, but a national membership survey of the American College of Emergency Physicians in 2010 found that 90 percent of ER doctors believed frequent users were draining their emergency resources.
A third of the doctors reported working in a hospital that had a program dedicated to the reduction of frequent use. Such programs, often with a housing component, have been established in New York, Maine, Illinois, Minnesota, Connecticut and at least six California cities, just to name a few.
Hobson in Seattle explained that as frequent-user programs work their way down the list from the most costly enrollees to people who have rung up relatively modest five-figure public bills, the percentage of savings starts to ebb. Enrollees costing the public up to a half-million dollars a year are rare, he said, and when you reduce their bill with an effective program they no longer drive the savings equation.
After decades in business, his program still achieved a 53 percent taxpayer savings in 2007, according to an evaluation published in the Journal of the American Medical Association.
To do so, his program continues to attack frequent use, but also identifies clients through a “vulnerability” index that enrolls homeless men and women most likely to die on the street — the humanitarian mission on equal footing with the financial goals.
Maienschein said if Project 25 reaches its goals of becoming Project 50, 100 and so on, it could also shift focus.
“I agree with him,” he said of Hobson’s observation that such programs usually show the biggest savings early on. “The universe of frequent users will dwindle. ... When that happens, there will still be the humanitarian aspects of the program.”
He added that his program’s future could not be foretold based on the experiences of other cities.
“What happens in Seattle, good, bad, or indifferent, has to do with their political environment, their city dynamics,” Maienschein said.
In San Diego, Dunford, who still pulls regular emergency room shifts, has worked on a parallel track to identify frequent users in a way that no other city has done.
He has compiled detailed computer records and wants to use them to do everything from identifying frequent users who have strayed from Project 25 — a common problem in all frequent-user programs — to flagging new frequent users who come to the city.
Dunford said this will allow him to locate frequent users wherever they are, “whether it’s in the street, a living room in Point Loma or a downtown hotel room.” His effort, called the Community Information Exchange, received a $250,000 grant in December from the nonprofit Alliance Health Care Foundation.
Another frequent user program — dubbed Project 50 in Los Angeles, but with no ties to San Diego’s Project 25 — does not have the advantage of such electronic, on-the-street data to identify and keep track of clients.
The four-year-old program, much like Maienschein’s vision for San Diego, has expanded from the enrollment of 50 Skid Row clients to efforts in other parts of the city: Venice, Santa Monica, the San Fernando Valley.
It now has 250 clients housed, and is working with the Veterans Affairs Department to enroll former servicemen and women at high risk. Veterans’ needs are amplified in San Diego, where they comprise an estimated 35 percent of the city’s homeless.
But Project 50 in Los Angeles still relies primarily on caseworkers to screen clients through old-fashioned gumshoe work. That has led to pitfalls for other programs, said Flora Gil Krisiloff, a senior field deputy who spearheaded creation of Project 50 for Los Angeles County Supervisor Zev Yaroslavsky.
She said convincing frequent users to sign up can be exhausting for outreach workers who track them down in dangerous street conditions that are a society unto themselves. Workers can be tempted, she said, to turn to clients they have an existing relationship with — not necessarily the most extreme frequent users.
“You have to be sure this is somebody who is vulnerable,” Gil Krisiloff said. “So you’re not doing what has been done in the past, creating enrollment where the easiest people end up being served.”
She said the Los Angeles effort, like Seattle, uses a vulnerability index, a checklist of client desperation and need that must be met before enrollment is finalized.
Even with San Diego officials investing in unprecedented electronic outreach measures that use objective data, directors of other programs still have words of caution.
They say that bread and butter public impact — pothole filling — could prove elusive without legislation that earmarks how savings should be used.
In Seattle, directors supported local legislation in 2011 that would have earmarked public savings realized through their program for public housing and medical services.
In a city known for its liberal culture, it still lacked political traction, and the savings were instead used to help justify further cuts to medical services. The reward for efficiency became a reduced budget.
Maienschein balked at promising to guide a direct reinvestment in municipal services. The assembly candidate said he would continue to support Project 25 if he won office, but ruled out advocating legislation that would earmark how savings were used.
“I think that the data and the results are really going to tell a great story on their own,” he said.
But the data isn’t the whole story, he acknowledged.
“There are a ton of potential issues...” Maienschein added. “I don’t know where everything is going to be in three years, in five years.”