Patient Care: Managing High Need, High Cost Medical Patients

In 1995 the New York City Police Department introduced the concept of COMPSTAT, where police data are mined and mapped to show where the city's crime problems concentrated -- and to direct police activity to where it is most needed. This method is now used successfully around the world. A similar approach is emerging in medical care in order to identify those patients who have the highest needs, and the most costly of services with little evidence of benefit, and thus to better direct needed and effective interventions to help these individuals feel better and be less of a drain to state treasuries.

Atul Gawande, M.D., was all over this idea in a wonderful article in The New Yorker (January 24, 2011) that he called "The Hot Spotters." But we want to take his remarkable piece a step further. We do so by using the same laser approach but shining it more fully on mental health and substance use disorders -- which turn out to be hugely disproportionately present in those who are in the most need of better care and where significant opportunities exist to save money.

Consider this: In New York State, with one of the largest medicaid populations and budgets in the USA, 2007 data reveals that $814 million was spent on what are called "potentially preventable (hospital) readmissions (PPRs)," namely people who had a hospital stay that either did not leave them well enough to avoid readmission or they lacked good community-based followup so that they became, again, acutely ill and received another (potentially unnecessary and expensive) inpatient stay within 30 days. Of the $814 million, almost half ($395 million), was for medical admissions (e.g., heart disease, diabetes, pneumonia, trauma) of people with mental health and substance use disorders. Those readmitted for mental health and drug abuse stays, alone, totaled $270 million. Thus, taken together, $665 of the $814 (more than 80 percent!) was spent, perhaps unnecessarily, on people with mental disorders, principally for the serious medical illnesses that they frequently suffer. Among health policy gurus, these individuals are called the 'trimorbids' -- people with health, mental health and alcohol/drug disorders.

Consider this: In Missouri, 5 percent of their high risk, high need medicaid recipients (many with mental health and substance use disorders) represented 93 percent of the costs for hospital readmissions of people considered to have had conditions that would be responsive to outpatient services. These people, too, are the badly over served.

By the way, the medicaid costs exemplified above two states costs do not include jails, prisons, shelters and social welfare expenditures.

Remarkably, in New York State, and elsewhere, we have the tools to make a difference! In New York City, a partnership between the city and state governments is using medicaid data to map service use in high-need individuals with mental health problems. This "Care Monitoring Initiative (CMI)" provides "alerts" that specify individuals known to have histories of high acute service needs and who: have not filled psychiatric medication prescriptions (for more than 60 days); have not received community-based mental health services in the prior 120 days; or have had two or more psychiatric inpatient admissions or emergency room visits in the prior 120 days. The CMI takes the approach Gawande describes in "Hot Spotters:" to achieve meaningful changes in health care quality and cost, we must target those with the greatest needs and most complicated conditions.

We can now detect and monitor those who are "falling between the cracks" and need better care. And mental health and substance-use interventions have become quite refined so we also know what works. We have evidence based practices for what medications and counseling therapies work best for people with serious mental illness. We also have strong scientific evidence that case management, including health coaches and peer counselors, reduces the use of acute care psychiatric services in people with serious mental illness, and improves their lives.

We know that wellness efforts (like diet, exercise, yoga, meditation, massage) improve health and can reduce medical care. We know that quitting smoking makes a huge difference in health, well being and longevity. We know that people with serious mental illnesses can stay in school or go to work, but they need specialty programs that enable them to do so.

We know that fee-for-service payment, where the more a doctor does the more she/he is paid, incentivizes doing more, not necessarily doing better (the same applies to hospitals). We know that the more patients must pay for a part of their care (through co-payments and deductibles) the less likely they are to pursue necessary (and unnecessary) care -- one reason why parity for mental health and substance abuse benefits was finally federally legislated last year.

We have the tools, but we lack the traction to use them. While many provider agencies and caregivers deliver effective and compassionate care, there is no system in place to coordinate care across agencies or to engage people who have dropped out or been lost to care. One careful case review, undertaken after a tragic outcome in NYC, had us refer to that case as "Nobody's Patient." A core deficit in the mental health "system" is the absence of any ongoing accountability to and for patients. The Institute of Medicine calls this "continuous healing relationships." We know what to do, but are not organized or authorized to use the tools we have. The consequences are continued suffering for patients (and families) and often crushing social and economic burden.

The current crisis in health care, especially medicaid, provides what we like to call a "perfect storm" of opportunity. Severe financial constraints; the demand for enhanced health care quality; and growing and inescapable evidence that we have the tools to do a lot better create the critically needed impetus for real change. Now is the time to realign the health care system to prioritize and effectively serve those with the greatest needs (and costs).

What is needed is going from monitoring to care management that is focused on solving our two greatest problems: 1) overuse of emergency and acute (inpatient) health and behavioral health (mental health and substance abuse) services and 2) failure to engage and retain high need individuals in care so they are not lost to care.

The critical factors that a care management organization must deliver include effective coordination among mental health, substance abuse and health services; engagement with county governments (it is different in rural, upstate New York than it is in New York City, just as it is different in rural Arkansas than it is in Little Rock); clear, measurable performance measures such as true access to clinicians and evidence based treatments as well as improvements in functioning; a range of treatment venues (not just inpatient, emergency room and clinics but also, for example, crisis services and rehabilitation services); outreach, engagement and retention in care achieved by peer coaches and system navigators; joint programming and privileging by government agencies and community providers; and ongoing and accessible training of clinicians in what are the right treatments at the right time for patients in the varied course of their illnesses (using distance learning techniques that universities have already mastered).

Will Rogers was fond of saying, " ... even if you are on the right track, if you just sit there you will be run over." We are getting run over. People are not getting effective care; medicaid budgets are swelling and threatening the fiscal viability of every state. Leadership is needed to close the gap between what we know and what we are doing. Leadership, however, will be pursuing goals that are not yet popular.

This blog was written with Thomas E. Smith, M.D.


  1. Smith, TE, Sederer, LI. Changing the Landscape of an Urban Public Mental Health System: The 2008 New York State/New York City Mental Health-Criminal Justice Review Panel. Journal of Urban Health, Bulletin of the NY Academy of Medicine. No. 87, Vol. 1, January 2010, pp 129-135.
  3. Smith TE, Appel A, Donahue SA, Essock SM, Jackson CT, Karpati A, Marsik T, Myers RW, Tom L, Sederer LI: Using Medicaid claims data to identify service gaps for high-need clients: The NYC Mental Health Care Monitoring Initiative. Psychiatric Services. Vol. 62, No. 1, January 2011; pp 9-11.


Dr. Smith is a faculty member in the Department of Psychiatry at Columbia College of Physicians and Surgeons, and is Co-Director of the New York City Care Monitoring Initiative.

Drs. Sederer and Smith receive no support from any pharmaceutical or device company.

Visit Dr. Sederer's website at -- for questions you want answered, reviews and stories.