New Marketplace

Caring for High-Need, High-Cost Patients

Article · August 15, 2016

Improving the performance of America’s health system will require improving care for the patients who use it most: people with multiple chronic conditions that are often complicated by patients’ limited ability to care for themselves independently and by their complex social needs. Focusing on this population makes sense for humanitarian, demographic, and financial reasons.

From a humanitarian standpoint, high-need, high-cost (HNHC) patients deserve heightened attention both because they have major health care problems and because they are more likely than other patients to be affected by preventable health care quality and safety problems, given their frequent contact with the system. Demographically, the aging of our population ensures that HNHC patients, many of whom are older adults, will account for an increasing proportion of users of our health care system. And financially, the care of HNHC patients is costly. One frequently cited statistic is that they compose the 5% of our population that accounts for 50% of the country’s annual health care spending.

At least three steps are essential to meeting the needs of these patients: developing a deep understanding of this diverse population; identifying evidence-based programs that offer them higher-quality, integrated care at lower cost; and accelerating the adoption of these programs on a national level. Although we are making progress in each of these areas, much work remains.

As we characterize the HNHC population and its needs, we should avoid stereotypes and oversimplification. For example, some observers mistakenly believe that most HNHC patients are near the end of life. In fact, the population is clinically diverse. Some have multiple chronic conditions that are stable with treatment and will persist for years. Others have extreme functional limitations. Some have mostly severe, persistent behavioral health challenges. Others have conditions that are greatly exacerbated by social factors such as lack of housing, food, and supportive personal relationships.

Research is under way to segment this diverse population into more homogeneous subgroups with similar health care requirements. This process is critical to designing effective interventions, because programmatic effectiveness and efficiency increase dramatically when we can target the people most likely to benefit from specific interventions.

Several promising program models have demonstrated success in meeting the needs of HNHC patients.1–4 Some focus on managing transitions of care — for example, from hospital to home, rehab facility, or nursing home — that are common but risky for patients with complex conditions. Some extend primary care teams by integrating nonmedical services, such as the National Center for Medical-Legal Partnership or Health Leads (Massachusetts). Others focus on interdisciplinary, person-centered primary care. These include the Geriatric Resources for Assessment and Care of Elders (GRACE) program and the Program of All-Inclusive Care for the Elderly (PACE), which was developed decades ago in San Francisco and has spread to 118 locations in 32 states.

Successful interdisciplinary primary care programs share a number of attributes, including careful targeting of interventions to persons most likely to benefit (thus the need for segmentation of the population); close (usually face-to-face) communication and coordination among members of the care team, including physicians, nurses, and care managers; strong information technology support; and promotion of patient and caregiver engagement in the care process.

Although we have promising models with solid results, few have spread beyond the demonstration stage to become the standard of care throughout the country. One obstacle to wider diffusion is the nature of the programs. They tend to be complex and novel, with many moving parts — new types of personnel, such as care managers; new information technology capabilities; new tasks, such as home visits. Some require not only changes in behavior and clinical workflow but also cultural adaptations as professionals assume new roles on the care team. Spreading new models of care for HNHC patients is vastly more difficult than disseminating new drugs or devices, and even those more discrete innovations can take decades to diffuse.

Another obstacle to spread has been financial. Putting new programs in place often requires up-front investments by health care providers, but the financial results, including reduced use of outpatient and inpatient care, run counter to the incentives in the prevailing fee-for-service reimbursement system. In some cases, innovators have not made a compelling business case for adoption. Better care delivery should demonstrate improved clinical and functional outcomes, improved patient engagement, and an increase in clinician satisfaction — all at an acceptable, and even reduced, total cost.

Fortunately, a number of recent changes in the organization and financing of care may reduce some of these obstacles to widespread adoption. One is a movement toward value-based payment by both public and private payers. Value-based payment comes in many forms, but most involve rewarding providers for controlling costs of care while maintaining or improving quality. Under the Affordable Care Act (ACA), 838 accountable care organizations have formed, collectively covering more than 28 million people.5 Under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA), physicians will face strong incentives to join so-called alternative payment models. These approaches increase providers’ accountability for the quality and cost of care. In addition, the growing enrollment in Medicare Advantage plans and Medicaid managed care also increases the prevalence of value-based payment.

To succeed under value-based payment arrangements, providers must contain the costs and improve the quality of care for populations that use the most resources and are at risk for encountering serious problems with the quality of care — that is, for HNHC patients. These changed incentives create an important new opportunity for the diffusion of models that have been slow to spread in the past.

For all the imperfections of health information technology, its increasing prevalence creates an essential platform for implementing applications to manage the care of HNHC patients. Health information technology is also critical for gathering data needed for better targeting of programs through the use of predictive modeling that identifies patients who are likely to become HNHC in the future. Providers can then intervene early to improve or maintain those patients’ health. The availability of vast amounts of digitized data from medical records and other sources creates new opportunities to perfect such methods, but the work has barely begun.

Furthermore, even the most promising models of care for this patient population are far from perfect and need to be evaluated and improved as they are implemented more widely in varied settings. And even when financial incentives are better aligned, the organizational, professional, and management challenges of bringing effective models to scale will warrant greater attention. Novel incentive schemes under the ACA, MACRA, and other initiatives are themselves experimental and will require evaluation and refinement.

Higher-quality, more affordable care for HNHC patients will require new levels of collaboration among health care providers, payers, communities, social service organizations, academics, researchers, and others. Our five foundations will work together to improve our nation’s capabilities in all three of the vital areas noted above: clarifying the needs of HNHC patients, elucidating the best ways of caring for them, and assisting with the spread of proven approaches. We welcome the involvement and support of all stakeholders seeking to improve the performance of our health system by ensuring better care for this vital and growing population.


SOURCE INFORMATION

From the Commonwealth Fund (D.B.), the John A. Hartford Foundation (T.F.), and the Peterson Center on Healthcare (J.S.) — all in New York; the SCAN Foundation, Long Beach, CA (B.C.); and the Robert Wood Johnson Foundation, Princeton, NJ (J.L.).

1. Hong CS, Siegel AL, Ferris TG. Caring for high-need, high-cost patients: what makes for a successful care management program? New York: The Commonwealth Fund, 2014.
2. Rodriguez S, Munevar D, Delaney C, Yang L, Tumlinson A. Effective management of high-risk Medicare populations. Washington, DC: Avalere Health, 2014.
3. Anderson GF, Ballreich J, Bleich S, et al. Attributes common to programs that successfully treat high-need, high-cost individuals. Am J Manag Care 2015;21:e597-600
Web of Science | Medline.
4. Rieder C, Langston C, Berman A, et al. Achieving better chronic care at lower costs across the health care continuum for older Americans. Washington, DC: Engelberg Center for Health Care Reform, 2010.
5. Muhlestein D, McClellan M. Accountable care organizations in 2016: private and public-sector growth and dispersion. Health Affairs Blog. April 21, 2016 (http://healthaffairs.org/blog/2016/04/21/accountable-care-organizations-in-2016-private-and-public-sector-growth-and-dispersion).

 

This Perspective article originally appeared in The New England Journal of Medicine as “Caring for High-Need, High-Cost Patients — An Urgent Priority.”

New Call for Submissions ­to NEJM Catalyst

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From New Marketplace
Effect of Value-Based Payment Programs on Providers That Serve the Poor

Financial Incentives and Vulnerable Populations — Will Alternative Payment Models Help or Hurt?

Understanding APMs’ potential consequences for vulnerable populations is critical if we wish to maximize benefits and reduce harms.

Example 4-Quadrant Analysis and Price Setting for a Single-Procedure Bundle - Lessons Learned from DRG Implementation

Making Bundled Payments Work: Leveraging the CMS DRG Experience

Given its clout and experience, CMS is uniquely positioned to lead the U.S. health system toward high-value care. Bundled pricing based on real costs, leveraging lessons from DRG implementation, would establish the right types of provider incentives.

Kocher03_pullquote risk-based primary care provider

Opportunities for Risk-Taking Primary Care Providers

Embracing two-sided risk while adopting workflow redesign and reviewing benchmarks is leading to improved clinical and financial outcomes.

The Unrealized Potential of EMRs: Interoperability and the Opportunity for Disruption

NEJM Catalyst hosted clinical and business leaders, along with the originator of “disruptive innovation,” to consider the user frustration, high cost, and lack of interoperability of electronic medical records.

Steven Seltzer Andrew Menard Clayton Christensen Edward Prewitt Electronic Medical Records Roundtable Head Shots

The Unrealized Potential of EMRs: Why They Fall Short and the Unexpected Source of a Solution

NEJM Catalyst hosted clinical and business leaders, along with the originator of “disruptive innovation,” to consider the user frustration, high cost, and lack of interoperability of electronic medical records.

Robert Gavin head shot

Amazon and CVS: Short-Lived Unicorns in Health Care, or Healers of the “Tapeworm”?

Will Amazon–Berkshire Hathaway–JP Morgan and CVS-Aetna change the health care game? To one health care employer purchaser, these announcements feel a lot like Groundhog Day.

Fiona Scott Morton head shot

We Can’t Spend All Our Money on Health Care

We have to think about how much we want to spend on health according to how much it’s worth to us at the margin.

Simplified Chain of Production for Primary Care Services Generating Retail Prescriptions. Solid arrows indicate contractual relationships or ownership, and the dashed arrow indicates referral for prescription.

Does CVS–Aetna Spell the End of Business as Usual?

What might one of the largest mergers in history mean for the health care delivery system?

Lack of Incentive Is Top Barrier to Implementing Value-Based Payment

Survey Snapshot: Payer-Provider Alignment Is Difficult Even for Integrated Organizations

NEJM Catalyst Insights Council members say stronger incentives and better use of analytics could improve alignment.

Kaplan04_pullquote Time to Sink Two Canoe Payment Models Argument

Time to Sink the Two-Canoe Argument

Although the transition from fee-for-service to quality-based payment can leave physicians feeling trapped “with a foot in two canoes” while straddling the two payment methods, there are compelling ethical, professional, and business reasons against rationalizing continued support of fee-for-service medicine.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

The Health System Crisis: A Call…

To overcome current failures within our health systems, we need to improve interprofessional education and…

Financial Incentives and Vulnerable Populations —…

Understanding APMs’ potential consequences for vulnerable populations is critical if we wish to maximize benefits…

Change the Model → Change the…

If we’re going to change the health care payment model, do we need to change…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now