The study did confirm that super-utilizers are expensive for the health care system. Costs associated with such patients averaged around $114,000 at the peak of their frequent ER (gateway to a hospital) and hospital use, and dropped to less than $50,000 after the second year as their hospital use tapered off. The study was part of a $20 million grant to Denver Health from CMS, to design better primary care delivery for the large safety net population the system serves.

“The study clearly indicates that there is no one-size-fits-all solution to reduce avoidable hospital utilization,” Johnson said. “There are a lot of subgroups in this population and their needs are different.”


She said that Denver Health is already deploying solutions based on the research. For example, the data helped make the decision to open an Intensive Outpatient Clinic to help complex, chronically ill patients with medical, mental health, substance abuse and case management services.

Key features of this primary care clinic include real-time patient identification, outreach to patients while still hospitalized, and embedded social and behavioral health support. This keeps patients out of the hospital and in an outpatient setting that improves health and reduces costs.

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