Repeated hospitalizations and visits to the emergency room. One or more chronic medical conditions. Being physically unable to perform routine activities of daily living. Undiagnosed mental health issues. Difficulty paying rent. Lack of access to healthy food. These are all characteristics that in different combinations describe high-need, high-cost (HNHC) patients. We know that these patients make up 5 percent of the population but account for 50 percent of health care costs. As a result, HNHC patients are receiving heightened attention because they have serious health care challenges and are likely to benefit from targeted care management.
Why is it so difficult to treat HNHC patients? People with complex needs are heterogeneous. Some HNHC patients have multiple chronic conditions and complex needs. Other patients might be older with an advanced illness or have difficultly dressing and feeding themselves. Because of their diverse health care needs, no single treatment approach will work for all HNHC patients.
A patient with a diverse combination of needs might also see many different providers. That can be an uphill battle when health care organizations aren’t set up to coordinate the patient’s care across multiple providers in different care settings. This disconnect often leads to fragmented care and high costs to patients and providers. In addition, many HNHC patients also have underlying behavioral health conditions and social needs that directly affect their health, including high levels of homelessness, mental illness, or substance abuse.
All of this means that the full spectrum of HNHC patients’ needs might not be adequately served by traditional medical care delivery models, which sometimes emphasize treating individual conditions or place less emphasis on helping to address the social and behavioral needs that contribute to these conditions.
What can be done? Given that a growing number of health care delivery organizations are taking on increased financial responsibility for their patients’ health outcomes, it is important for the health care community to better understand how to improve the quality of care for HNHC patients and best use health care resources. To support these efforts, some organizations are using different methods to easily identify HNHC patients and then identify subgroups of patients with similar health care, behavioral, or social support needs, enabling providers to better tailor their care management. For example, an HNHC patient who has diabetes and depression might benefit from enhanced care management by a nurse and a clinical social worker who work closely with the patient’s primary care physician.
What does the research say? Previous research has provided a snapshot of high-need patients’ key characteristics and delved into the use of subgroups to align similar patients with care models that meet their specific needs. A recent Mathematica working paper aimed to learn more about the use of HNHC subgroups in health care delivery systems and whether this approach showed promise. This paper, supported by the Commonwealth Fund, identified existing strategies to group patients and provide tailored care management that achieved one or more of the programs’ goals, but much of the research did not comment on outcomes. This might be because these efforts to identify subgroups of HNHC patients and then tailor care management to such groups are in an early stage, samples within HNHC subgroups are small, and there has not been enough time to systematically evaluate results.
Additional HNHC research at Mathematica includes a peer-reviewed journal article that looked at care management services from the patient perspective. The research showed that although patients’ perceptions of care management were mixed, those who had both regular contact and a desire to work with their care manager valued the care management services they received.
Mathematica’s working paper on HNHC patients demonstrates that there are different approaches health care providers and systems can use to identify HNHC patients and, when they are identified, there are different strategies care managers can use to better engage HNHC patients. Although findings from the working paper indicate that some health care delivery systems developed new approaches for identifying and treating HNHC populations, we still need to better understand exactly what is working, what is not working, and how successful processes can be replicated on a larger scale, which will require more comprehensive studies within and across systems.
What’s next? We need to further study how health care organizations use the identified subgroups of HNHC patients to specifically tailor health care resources to those groups. In addition, to better understand potentially promising practices, health care organizations and stakeholders should support research into how the organizational structure (that is, size, ownership type, and governance) and differences in patient populations or payer type (that is, Medicare, Medicaid, and commercially insured) affect outcomes for HNHC patients. By focusing additional research resources on promising practices to address the needs of HNHC patients, the health care community can identify additional interventions that will help provide better care and more effectively use resources to treat this critically important patient population.