By Mark Wallace

Too often, bedbugs get in the way of delivering cost-effective, efficient, high-quality health care – both literally and figuratively.

In the literal sense, consider a case of a middle-aged woman I’ll call Mary. A frequent visitor to emergency rooms in northern Colorado, Mary brings with her a long list of complex medical problems. She takes multiple prescription medications and suffers from behavioral health issues and chronic pain.

Recently, a pilot project implemented by the North Colorado Health Alliance in cooperation with Colorado Access and Rocky Mountain Health Plan sought to determine why people like Mary keep returning to emergency rooms. Known as the Community Care Management team, the group consists of a broad range of providers from different walks of the health care system. Our team evaluates clinical and billing data and determines how to intervene to improve the quality of care, enhance the patient experience and control costs.

Assessing Mary’s situation, our team identified that almost no home health agency in Northern Colorado would visit Mary’s home because it was infested with bedbugs. Unfortunately, Mary herself lacked the financial means to deal with the infestation. As long as the problem persisted, she’d likely return to emergency rooms again and again because the bedbugs prevented Mary from receiving the kind of community-based care she deserved from in-home providers.

Putting their heads together, our team arranged to fumigate Mary’s house and replace her mattress – at the cost of $380. Of course, we couldn’t bill Medicaid for eliminating the bedbugs or replacing Mary’s mattress. But by making these simple arrangements, our team kept Mary from many repeated hospital visits (ranging in cost from $1,200 to $2,400 each) by focusing on the social and environmental factors affecting Mary’s health outside of the traditional health care system.

There are numerous social “bedbugs” just outside the health care sector that negatively impact individuals’ health. In more abstract terms, these factors are known as the “social determinants of health” – the economic, environmental, behavioral and social conditions that influence individual and group differences in health status. Collectively, they are the circumstances in which people are born, grow up, live, work and age.

In fact, the U.S. Department of Health and Human Services estimates that only 10 percent of health is influenced by health care, with factors such as income level, education, transportation, food insecurity, environment and personal habits such as smoking, drinking and obesity rounding out the other 90 percent.

Mary’s case (and subsequent “treatment”) underscores a growing acknowledgment among health care professionals that the social and behavioral determinants of health are critical in improving health outcomes. In order to serve the needs of the 2 percent of the population who are driving up 50 percent of health care costs, we must take a closer look at what’s happening outside of hospital and clinic walls to determine what might be the root cause contributing to poor health. It’s not always physical health issues that significantly impede good health.

That’s why the model developed by Jeffrey Brenner, MD, a family doctor from Camden, N.J., holds much promise in changing health care as we know it.

Brenner, who will speak at the Colorado Health Symposium later this month, uses medical billing data from emergency rooms to map out “hot spots” of the city’s most costly patients. His groundbreaking efforts (better known as “hot-spotting”) have been profiled by acclaimed health care writer, Atul Gwande, M.D., in The New Yorker as well as in the PBS news show “Frontline.”

Taking medical billing data he gathered from emergency rooms, Brenner targeted the sickest and most expensive patients in Camden. With support from medical foundation grants, he assembled a team of medical “hot-spotters,” which included nurses, social workers and physicians’ assistants, who make follow-up calls and home visits to those who receive care.

In just three years, Brenner’s team has provided organized care to more than 300 people. In some cases, Brenner said this innovative approach has delivered cost reductions as high as 50 percent, while also reducing emergency room visits and improving individuals’ health as well as their experience with the health care system.

Dr. Brenner’s model in large part inspired the North Colorado Health Alliance’s efforts to move away from siloed traditional health care models and spend more time in integrated teams with the people we serve in the environments in which they live. In fact, I still carry The New Yorker piece, published about 18 months ago, in my briefcase.

In implementing our own version of “hot-spotting,” our community-based care management team works within what we call the “interstitial spaces” where people can get lost in the health care system (i.e., between a family practice center and a hospital, between the hospital and a diagnostic center and between the diagnostic center and a nursing home). We build on the strengths of the individual, the patient-centered health care home and the community.

Working with providers throughout northern Colorado, we rely on claims data, real-time data feeds from hospitals, as well as our own electronic health records to serve the patient’s best interest.

The approach complies with the Health Insurance Portability and Accountability Act (or HIPAA) and protects patients’ privacy and security.

The Alliance began aggressively implementing a hot-spotting model in April, and I’m already convinced it’s an effective model that could become a key part of reforming health care in Colorado and beyond.

But hot-spotting also is potentially disruptive to the health sector because it is so different than the traditional model. It is a game-changer that requires building trust between many different organizations and providers.

The practice of hot-spotting also raises some big questions about how we as a society can bridge the deep divides in health care – the theme of this year’s symposium. I look forward to hearing Dr. Brenner, and others address those questions, July 25-27.

Like the bedbugs I alluded to earlier, many social determinants of health could be eliminated with the right approach and care. But if left unchecked, they ultimately impact the health and well-being of many.

Mark Wallace, MD, MPH, is president of the North Colorado Health Alliance and director of the Weld County Department of Public Health and Environment. He also is a member of the Colorado Health Foundation’s Philanthropy Committee.