The Impact of 'Superutilizers' on Pharmacy Spending

So-called “superutilizers” are one of the biggest health care crises facing the United States.

These patients, who typically have multiple comorbid conditions, siphon off a disproportionate share of health care dollars, and typically have a poor quality-of-life, due to frequent hospital stays or other interactions with the health care system. A recent study from the nonpartisan Government Accountability Office (GAO) found that just 5% of Medicaid beneficiaries account for almost 50% of program spending.

The most expensive 25% accounted for more than 75% of the expenditures. Meanwhile, the least expensive 50% accounted for less than 8% of the Medicaid dollars spent, while about 12% of enrollees had no expenditures at all. Pharmacists, who are often the only health care provider with a 360-degree view of a patient, have an important role to play in identifying these superutilizers.

Pharmacists help to uncover the causes of avoidable health care overutilization, and develop strategies to appropriately intervene with the goal of improving outcomes and lowering costs. Identifying superutilizers Pharmacists are well-positioned to identify superutilizers, along with those at risk for becoming superutilizers, by using prescription data to target consumers taking the largest number of medications.

After all, prescription non-adherence is one of the leading causes of avoidable hospital readmissions, which is a common outcome for superutilizers. One recent study found that the average all-cause 30-day readmission rate was 4 to 8 times higher for superutilizers than for other patients.

Among patients under 65, superutilizers accounted for more than half of all 30-day readmissions. Another tactic is to target all patients with specific conditions known to be over-represented among superutilizers.

For instance, the GAO Medicaid study found that superutilizers—the top 5% in terms of expenditures—were more than 6 times as likely to have diabetes (18.8%) as the overall Medicaid population, where only 3% of patients had diabetes. The GAO study also found that superutilizers were nearly 4 times as likely as the general Medicaid population (52.6% versus 13.6%) to have mental health conditions.

These conditions often require treatment with multiple medications, and may be exacerbated by lifestyle factors, such as diet and stress. Superutilizers with these complex conditions require effective medication monitoring and advanced adherence strategies that consider the patient’s other conditions, plus any demographic or socio-economic factors that may get in the way of patients staying on therapy and out of hospitals.

Uncovering the causes of overutilization

Once the pharmacy accurately identifies superutilizers, either among their customer base or as a subset of patients prescribed a certain drug class, they can deploy specific interventions designed to address barriers to proper use of medications. Patients may be unable or unwilling to take their medications as prescribed for a host of reasons. They may be experiencing side effects, dementia or other memory problems may pose a hurdle, or they may be struggling with an unstable home life that makes it difficult to stick to routines.

While most discussions of medication nonadherence centers on patients who do not take their medication, another significant problem among superutilizers is taking too much medication, either inadvertently or because they are suffering from addiction. Pharmacists can play a vital role by stepping in to improve care coordination by providing proper medication reconciliation. When patients are discharged from the hospital, they frequently are prescribed new drugs, but they fail to discontinue old drugs which are no longer indicated.

Patients risk serious adverse events if they take drugs that either amplify or negate each other’s effects. A growing number of hospitals are recognizing the crucial role pharmacists can play in providing proper medication reconciliation by placing pharmacists within the hospital to assist with discharge activities, and to make sure that patients understand which drugs to stop taking.

When it comes to addiction, the pharmacist can truly be the eyes and the ears of the health care system. Pharmacists will probably be the first to notice that patients are trying to refill prescriptions earlier than allowed, or that that same drug has been prescribed to the same patient by multiple doctors.

Deploying intervention strategies

The pharmacy has a leading role to play to help superutilizers avoid drug interactions, anticipate obstacles to adherence, and engage those who may feel marginalized by their health status. Technology can help pharmacies to:

• identify patients who need interventions
• reduce breakpoints in care transitions
• streamline communications with both patients and providers

The biggest challenge for pharmacies is the ability to carve out additional resources to engage with superutilizers, and help turn them into “better utilizers.” Using technology solutions that separate adherent from non-adherent patients—and then further striate patients to identify superutilizers—will help pharmacies direct automated communications to adherent patients, while offering non-adherent or superutilizers the opportunity for more intensive one-on-one touchpoints with a pharmacist.

To give their best to the patients who need them most, pharmacists must employ strategies that allow them to scale medication adherence programs without adding significantly to staff.

Pharmacies have the potential to serve as an important health care nexus for the hardest-to-reach patients, superutilizers.

By putting a face on a health care ecosystem that can feel impersonal and fragmented, pharmacists may be able to influence superutilizers to adopt healthy medication habits. This would go a long way to improve care coordination, reduce hospital readmissions, and improve transitions of care.

But pharmacies must find a cost-effective means of providing a deeper level of service to superutilizers while managing a growing volume of patients overall. Leveraging new communications technologies can ease routine administrative tasks for pharmacists, help identify the patients at greatest risk for non-adherence, and simplify reporting and leverage analytics to improve care. By offloading rote tasks, pharmacists will have more capacity to connect with the neediest patients.

About the Author

Robert J. Dudzinski is executive vice president for West Corporation. Dr. Dudzinski received his doctorate in pharmacy from the University of Nebraska Medical Center and has extensive experience in pharmacy benefit management, mail order pharmacy, home care, management information systems, and related industries, spanning a 30-year period. Dr. Dudzinski leads the Healthcare practice at West Corporation.