Manjula Julka, MD, MBA, FAAFP, Author at PCCI

30 December 2019

SDOH: Better management of high utilizers and the impact on the overall costs of care




For safety-net healthcare systems, helping patients with social needs such as transportation, food or housing, just makes sense from a mission perspective. But when it comes to creating a business case, it gets more complicated.

A recent Kaufman Hall survey of CFOs cited cost reduction, managing changing payment models and improving performance management as the top three challenges for health systems. So, while research may show impacts on costs and utilization from interventions that address social determinants of Health (SDoH), some organizations may not be willing to take the risk of investing in strategies that are outside their scope of service and may not show immediate financial returns. But I would argue that the impact of social determinants of health are everywhere in current health system operations and costs.

“High-utilizers”, individuals who suffer from a multitude of chronic diseases and often complex social/economic challenges, require intensive primary care, and frequently have issues with access, often gain the attention of financial and operational leadership, particularly if the organization has value-based contracts or large uninsured populations. In my experience, to truly manage this population requires addressing the upstream issues that are preventing them from leading and maintaining a healthy life. But with limited resources and time, health systems need to develop a clear strategy by understanding exactly which individuals to treat, and what intervention will best address their healthcare and social needs.

As a practicing clinician, I believe the critical success factor in developing this strategy is leveraging data science and technology to conduct a comprehensive data analysis of the target population.

    1. Analyze claims, clinical, social and economic data from your community at the individual and block level, to determine what social determinants are most impacting your high-utilizer population, such as lack of transportation, food insecurity etc. Finding key contributing factors and root-cause issues for your target population is critical.
    2. Test interventions that other health systems have found lead to improved cost savings and health outcomes. Start with issues with available solutions like transportation, referrals to food banks, and housing services.
    3. Engage external partners to help you execute the intervention, particularly social services and community-based organizations (CBO) that have expertise in addressing social needs, through a collaboration with a comprehensive governance model.
    4. Measure outcomes and adjust strategies as needed.

Scale your initial interventions to other populations, and/or move to more complex social needs.

SPOTLIGHT ON PATIENT CARE:
While some health systems may not be ready to dive into a SDoH strategy, but many realize that the cost of social determinants could already be impacting their daily operations:

1. High No-Show Rates in Clinics

Average no show rates in primary care clinics are 19% with specialty clinics rates running higher, with an average cost between $125 to $350 [1].  That can add up over the course of a year to significant revenue loss for health systems. Lack of transportation or access to affordable daycare play a big role in no show rates among other SDoH. An estimated 3.6 million people missed medical treatment due to transportation issues [2].

While many health systems and health plans have implemented programs with rideshare companies to solve this problem with some success [3]. Targeting the precise patient population that will benefit from rideshare services is critical. In addition to integrating and aligning transportation services for high-need patients, health systems should also explore other emerging technology and non-traditional option to bring services to where residents already are, instead of attempting to find ways to bring them to traditional healthcare access sites. For example, use of telemedicine and digital health as well as deployment of health services in non-traditional settings such as food pantries and or other CBO settings.

2. Unnecessary Emergency Department Utilization for Vulnerable Populations

 Dallas has the fifth highest city jail population, and emerging research suggests that underlying social, behavioral and health issues, particularly substance use disorders and mental illness, contribute to incarceration and recidivism, and that treatment, combined with seamless care continuity for individuals when they return to communities, can help prevent both [4]. Parkland Health and hospital system is designated care provider for this vulnerable population in Dallas. While inmates receive healthcare through Parkland Jail Health program, upon release many former inmates end up without support and in the Parkland emergency department (ED) to seek treatment, driving up unnecessary utilization and costs.

To prevent unnecessary ED visits or a return to jail, Parkland and PCCI are developing an intelligent discharge tool and predictive risk score, combining clinical, social (housing, transportation, job training access) and behavioral factors for inmates, to help connect those being released to community resources. We are also digitally the jail health, clinical providers and community providers on one secure technology platform to better generate real-time cross-sector referrals, track utilization and follow-up, and document services. As a result, transition plans for inmates will comprehensively incorporate medical, employment and financial support like resources.

3. Manage Transitions of Care

Hospitals across the country often struggle with providing homeless patients transitional care to post-acute care facility. If an appropriate place cannot be found, many of these patients stay in the hospital longer than necessary, increasing unnecessary inpatient utilization. And there are no signs of this issue abating anytime soon. In California, hospitals discharged homeless patients nearly 100,000 times in 2017, a 28% increase over 2015.

Two different programs in California have sought to mitigate these issues for hospitals and to assist patients with their social needs. In Los Angeles, the National Health Foundation opened a 62-bed facility for discharged hospital patients who needed less intensive medical oversight than a nursing home. At the facilities, patients have access to case managers for assistance with transportation, food and permanent housing. Area hospitals will often reserve beds at the facility for homeless patients, and L.A. Care Health Plan also leases beds there for their members.

In San Jose, Santa Clara Valley Medical Center created a one-year partnership with Skyline Health Center, a local nursing home. Skyline allocates fifteen beds to the hospital for homeless patients or patients who have no one to care for them at home. During the first ten months, 55 patients were sent to Skyline, and 42 were discharged, the majority to long-term housing programs or family members and friends. Of those discharged, only six were readmitted, a low number for this population [5].

About Manjula Julka 

Manjula Julka, MD, MBA is the Vice President of Clinical Innovation.  Dr. Julka would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.

[1] https://www.solutionreach.com/blog/which-wins-the-national-average-no-show-rate-or-yours

[2] https://patientengagementhit.com/news/overcoming-transportation-barriers-to-drive-patient-care-access

[3] https://patientengagementhit.com/news/do-rideshare-tools-reduce-transport-barriers-patient-no-shows

[4] Healthcare Plays Vital Role in Reducing Recidivism; EthicsDaily.com; November 2, 2017; https://ethicsdaily.com/report-healthcare-plays-vital-role-in-reducing-recidivism-cms-24443/; accessed July 14, 2019.

[5] https://khn.org/news/finding-homeless-patients-a-place-to-heal/

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17 July 2019

Reducing “Misbehaving” In Healthcare Operations Through Data and Optimal System Design




By Manjula Julka, MD, MBA and Albert Karam, MS

Every year, people throw away millions of dollars when they decide to fill up their car tanks with more expensive premium gas when regular unleaded will do just fine for their cars.

There are several reasons for that kind of sub-optimal behavior. Nobel Laureate and University of Chicago professor Richard Thaler calls it — “misbehavior”. Thaler, in his book “says that the optimization problems that ordinary people confront are often too hard for them to solve, or even come close to solving. Thaler’s two friends and mentors, Amos Tversky and Daniel Kahneman (himself a Noble Laureate) have illuminated several pathways on how we make decisions. Kahneman’s book “” articulates some of them and one of their decision theories may have applicability here. They say that when people make decisions, they do not seek to maximize utility. They seek to minimize regret. So, in this case, among other things, perhaps people are thinking that “better not regret causing any damage to the car for a few pennies”, not realizing that those pennies add up and that there’s no damage being caused.

Regardless of the root cause though, one of the ways to minimize these behaviors is to use data to educate and frame choices (the famous “nudge”) to make the optimal decision the easier one to make (through appropriate defaults etc.). And we see these kinds of suboptimal behaviors play out in every walk of our lives and healthcare is no exception.

At PCCI, we recently had an opportunity to work with a group of passionate clinicians at Parkland Health and Hospital System regarding a very similar issue. Magnesium is a key mineral for body functionality especially for heart, nerve, muscle and protein synthesis. Monitored in most hospitalized patients, it is often replenished to maintain normal levels. With very few exceptions, oral Magnesium is as effective as intravenous (IV) Magnesium medication with the added value of being significantly less expensive and more comfortable for patient (think premier gas versus regular unleaded). However, for a variety of reasons, the primary route of ordering Mg was through IV. To understand the magnitude of the problem at hand (and potential savings), we used Parkland’s EHR system (Epic) to identify instances where oral Mg could be as effective as IV Mg and realized that simply by changing the route for appropriate patients, the system could save hundreds of thousands of dollars. This analysis led to system-wide effort to provide informational messages to clinicians at point of care in the ordering process via the EHR so that they could make a more informed choice.

This initiative is a great example of how innovation, changes in behavior and optimal choices happen at the intersection of analytics, data and human behavior and psychology. Every care team member wants to provide the best care for patients, but sometimes the cumulative impact of individual decisions is lost. The conversion of one single IV order at a time to oral magnesium multiplied across many clinicians is now saving thousands of dollars to the hospital system while improving evidence-based care.

For additional technical details, please see 

4 September 2018

Family Doc to “Design Doc”!




“Hey doc, don’t you miss being a family doctor?”  is a frequently asked question over cocktails and during client meetings. My response is always the same, “Actually, I am still serving patients but in a very innovative way and on a much larger scale for better health and social impact. I am now a “Design doc.”

Positive Promotion

After 15 gratifying years of service as a traditional family doctor, I now enjoy taking care of patients by designing healthcare solutions that result in better patient experiences, lower costs, and increased quality. My new career as a “design doc” has been very rewarding.

Design with a Cause

Like any designer, impactful ideas put both the big picture and intricate details into context simultaneously. Taking into consideration questions like: How does a doctor think? What are a patient’s expectations, needs, and goals? And what are the high-precision treatment options available? Begin the innovative process of designing scalable healthcare solutions.

Care and Collaboration

By approaching solutions from a “design doc” perspective, I collaborate with healthcare executives, frontline care teams, services providers, and members of the communities we serve to combine the “art” of medicine with clinically engineered artificial intelligence. The result of these collaborations and insights are solutions that can augment clinical decision making at the point of care and facilitate timely coordination of care beyond the walls of service providers and into the community.

Same Goal, Different approach

Quality of patient care has always been top of mind both during my time in the clinic and my new role at the Parkland Center for Clinical Innovation (PCCI). I went from providing patient care to enabling providers to better care for their patients and the community through PCCI’s innovative solutions.

Learn more about PCCI’s careers, or stay up-to-date with our recent news by following us on FacebookTwitter and LinkedIn!

Photo via Thinkstock by Getty Images. Item number: 857015410.

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