Research spotlight: Rigorous Testing of Big Ideas - The Case of Healthcare Hotspotting

Healthcare Hotspotting:  A Randomized Controlled Trial

Researcher: Joseph Doyle

Healthcare Hotspotting describes the practice of finding geographic areas or patient groups that drive healthcare spending, and then addressing the clinical and social needs of these complex patients to improve their wellbeing and lower healthcare costs at the same time.  After all, about one-third of all healthcare spending is concentrated among 1% of patients; improving their care is a “big idea” in the re-design of healthcare in the US. 

The Camden, NJ Hotspotting program was pioneered by Dr. Jeffrey Brenner, and the program attracted national attention and replication in other markets.  To test whether this flagship program improves health and lowers costs, Dr. Brenner worked with MIT Professors Joe Doyle (HSI’s faculty director), Amy Finkelstein, and Annetta Zhou and Sarah Taubman to conduct a randomized evaluation.  The project was supported financially by MIT Sloan, the Jameel Poverty Action Lab, and the National Institutes of Health.   The MIT team designed, funded, monitored, and analyzed a study that randomly assigned newly-eligible patients to receive usual care or this innovative program.  Comparisons of outcomes for the two groups provides particularly credible evidence of the effects of the program.

The findings were published in the New England Journal of Medicine and showed that the program had no discernible impact on hospital utilization, despite claims that such programs result in large improvements along this dimension. The results suggest that these patients are particularly difficult to treat in ways that reduce their need for hospitalization.  As Dr. Brenner was quoted as saying, they built a way to navigate patients “to nowhere”.

Nevertheless, the idea of addressing the needs of complex patients is a powerful one, and the results show that new innovations are needed.  This could involve equipping the healthcare system with tools to aid these patients, such as ambulatory ICUs that provide remote patient monitoring for these complex patients.  Other promising innovations involve addressing key social determinants of health, such as nutrition, housing stability, and healthy behaviors in more targeted ways.

The importance of rigorous research.  A (naive) before-after comparison would suggest a high return on investment for this program, as utilization fell sharply after entering it. However, the control group showed the same decline, likely because enrolling patients who are identified as "super utilizers" runs into the evaluation problem of mean reversion: many of these patients will return to lower levels of care regardless of program involvement. Only by having a convincing comparison group can this be seen. "Such research takes more time,” acknowledges Doyle, “but this cost is worth the benefit of credible findings.  We need to know what works and what doesn’t to make progress."

1. In health care, does “hotspotting” make patients better? MIT News Office Jan 8, 2020

2. These Patients are Hard to Treat NYT, Jan 9, 2020

3. “Health Care Hotspotting — A Randomized, Controlled Trial" Amy Finkelstein, Ph.D., Annetta Zhou, Ph.D., Sarah Taubman, Sc.D., and Joseph Doyle, Ph.D.  New England Journal of Medicine, January 9, 2020

4. Looking at the Effectiveness of Healthcare Hotspotting with Joseph Doyle. The Hospital Finance Podcast, February 19, 2020.