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High users of health care: are we asking the right questions?


There is little doubt that system transformation is necessary to achieve sustainable and high-quality health care for Canadians. In recent years, the care and management of high users (HU) of health care has emerged as a focal point for developing a sustainable health care system.  Despite the focus on this group, one question has received surprisingly little attention: what is the relationship between high use of the health care system and population health – and more specifically, the social determinants of health (SDOH)? In Ontario, much of the attention on HUs has focused on ensuring appropriate and coordinated services for HUs to improve outcomes and reduce costs through Health Links. While better coordination of services is a laudable goal, we believe that if social determinants of health contribute to high use of the health care system, then health care providers must also address non-clinical issues such as housing and income.

The HU population is generally quantified as the top 1% or 5% of health care users. They are a small portion of the population that consumes a disproportionately high share of health care resources. In Ontario, the top 5% of health care users accounted for 58% of health expenses in 2007 and required complex, resource-intensive care. This population more likely to have multiple chronic illnesses, serious mental illness, come from disadvantaged population groups, be unemployed, and have limited social support.

It is well established that SDOH affect the health the health of us all. Yet there has been remarkably little research into the question of how SDOH affect health care resource use. However, the limited data we have points to a link. For example, although the diseases and illnesses driving HU burden vary little between socioeconomic groups, Canadian research suggests that SDOH both predispose the previously mentioned persons to becoming HUs and affect their health once in the HU group. Moving forward, we need to build on this research to better understand how SDOH affect health care usage, and we should be developing predictive models that include SDOH to identify potential high users before their illnesses advance to the stage where they become high users.

Given what we know about the impact of SDOH on health status and the evidence connecting SDOH with an increased risk of becoming a HU, we believe addressing SDOH may delay or prevent patient transition into the HU group and ensure better health outcomes for those in the HU group. Although SDOH are sometimes believed to be too large to tackle, they are not. There are actions that can be taken at both the system and the clinical level to address SDOH.

At the system level, we can reconceptualise Health Links to not only better coordinate medical care for HUs, but also address SDOH. An example of where this is done can be found in the work of Dr. Jeffrey Brenner, whose work on “hot spots” helped spark the focus on HUs, suggests that population health methods can achieve better health outcomes for HUs. Brenner  multidisciplinary team provide care beyond the hospital and clinic setting, including finding adequate housing for under-housed patients; encouraging group support for those with psychological illness; helping the unemployed apply for unemployment insurance; and contacting patients daily for medication reminders. Ontario’s Health Links are already forming the networks to better coordinating the care of HUs, but there is a risk they could continue to segregate clinical care and population health. We should build on approaches like Dr. Brenner’s and modify the Health Links program to coordinate not just clinical care, but also the broader social services to more fully address the social determinants of high cost use.

At the clinical level, there are many actions individual clinicians can take to address SDOH for their patients. For example, Canadian doctors have developed clinical toolkits for primary care providers to help them address SDOH in their offices. These include information about how to screen patients for negative social determinants of health as well as suggested interventions. And as a group, clinicians can collectively continue their work to raise the political profile of SDOH in Canada.

High users of health care present a substantial opportunity for us to make tangible improvements in health care provision. Health care providers and decision makers must focus on addressing HU needs beyond traditional clinic and hospital settings. Understanding and addressing SDOH is something all health care providers can do, and may be aided by Health Link support. These changes could produce economic efficiencies in both the short and long-terms, but helping to avoid hospitalizations and overall health care quality for HUs. Beyond the issue of economic sustainability, appropriate care for HUs will help address fundamental concerns of equity, efficiency, transformation, and the social determinants of health. The time to act is now!

Christopher Stone is a medical student at the University of Toronto. Laura Rosella is a scientist at Public Health Ontario. Vivek Goel is the CEO of Public Health Ontario.

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3 comments

  1. Ross Kirkconnell

    Great thoughts. As a Health Link lead, I can say this hits the nail on the head. In our Health Link work we are seeing three general categories of HUs: people who are simply ill (end stage heart disease, medically complex seniors and kids etc.); people use health and social services and a range of formal and informal supports; and people who are using the health care system as a proxy for all other supports. The opportunity here is largely with the latter two groups.

    Our Health Link work has largely focused on understand individuals’ stories, one by one. And in those stories, particularly among HUs in the latter two groups, we consistently hear about isolation, poverty, housing, loneliness, transportation and mental health. Factors that affect resiliency.

    %featured%The door to our Health Link approach is a Health Care door, in our case via primary care. But the solutions are not just Health Care solutions. Health care, social services, community organizations, employers, municipalities, police and others are all part of the solution. Through Health Links we hope for a different kind of engagement to elicit a different kind of approach. The individual stories require individual strategies. And these strategies must be community solutions that desegregate clinical care and population health and build individual resiliency.%featured%

    I think Health Links quickly understand the need to embrace a broader approach. The big challenges may well be at a higher level. Are organizations brave enough to revisit their mandates and reshape their work to meaningfully address SDOH? And will our various funders brave enough to let us?

  2. Dale Guenter

    I think most of us who eagerly raised our hands to volunteer for Health Links when they were first announced came with this sort of aspiration in mind. “Finally, we can start to do more of what REALLY works to improve the health of our high needs populations”. But the current that flows toward medicalized solutions seems to be stronger than ever, in part codified in the metrics we have been given by the Ministry, and in part just deeply entrenched in the human nature of we in the health system. The swim upstream is not easy!

    Could we ask our Ministry to lead us toward defining the top 2 SDOH to aspire to in Ontario? These would be the ones with greatest leverage potential, greatest evidence to support them, and would likely involve cross-sectoral policy. The Canadian Medical Association has started some excellent work on this. If I had to choose 2 today, they would be secure housing and living minimum wage, but the choice needs debate. Then let’s get the weight of the whole health system behind this. Hey, then maybe we could come up with a few HL metrics that serve these things we really believe in. How would that change our work?

  3. Hajira Tabassum

    Good article. As mentioned, focusing on SDOH would be one of the right steps to take in reducing the burden of HU on the health care system. Health Promotion is the key, and SDOH have to be taken into account while promoting health.

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