High-Need, High-Cost Patients: New Strategies of Care

The escalating cost of health care continues to be widely viewed as unsustainable. Spending in health care, projected to grow and consume 20% of our Gross Domestic Product by 2024, reached 19.7% in 2020, spurred by the COVID-19 pandemic.¹

The national payment models that promote value-based care promise to slow down this acceleration by sharing the risk of budget overspend with providers of health care. Accountable care organizations and payer organizations struggle to reduce costs by promoting efficiency and quality, and by reducing waste. However, a novel approach, which is gaining support, focuses on high-need, high-cost patients—the 5% of patients whose complex needs consume nearly half of every health care dollar spent.²

High-need, high-cost patients are adults who have 3 or more chronic diseases and functional limitations in their ability to care for themselves or perform routine daily tasks.³

In his 2011 New Yorker⁴ article, “The Hotspotters,” Atul Gawande brought national attention to the pioneering work of family physician Jeff Brenner. Analyzing public health and hospital data, Dr Brenner identified “hot spots” of care consumption in Camden, NJ, and focused his attention on the patients with highest hospital and emergency service utilization. He wrapped his primary care skills around individuals, confronting what we now readily recognize as the “social determinants of health.” The care model spread nationally, with small teams focusing on these “super-utilizer” patients. Although appealing in its simplicity and singular focus, a more recent study⁵ suggested that the expected decrease in hospital utilization did not happen.

In retrospect, Brenner’s innovative approach was spot-on, but it lacked an adequate infrastructure, sufficient influence over other providers, and financial incentives to support and reward the added work.

A renewed focus on high-need, high-cost patients is gaining widespread interest and investment. This time, financial incentives enable the investment of concentrated resources to care for high-need, high-cost patients, while paradoxically reducing costs.

Investors and insurers profit in exchange for taking on the financial risk of managing the total cost of care for an expensive subpopulation. Private investor funding has spurred the rapid growth of programs such as Oak Street Health, ChenMed, and Iora in Medicare Advantage plans. Meanwhile, value-based care innovators in the managed Medicaid space include AbsoluteCare and Cityblock Health. Managed Medicaid and Medicare Advantage, publicly funded but privately administered government programs, have provided more flexible Federal funding for value-based care organizations, allowing providers to apply creativity to care for high-need, high-cost patients. All of these programs are rooted in comprehensive primary care.

Complex patients benefit from the models that focus not only on their medical needs, but also on the social drivers that impede their well-being. Addressing upstream social needs is a key component to improving these patients’ health. In fact, without considering these drivers of poor health, the models will fail.

Better care for ambulatory sensitive conditions or those conditions that, when managed optimally in the outpatient setting, require fewer emergency medicine visits and hospitalizations results in reduced costs. By concentrating “upstream” on prevention and chronic care management, and on addressing the social determinants of health, fewer patients make it “downsteam” where disease progression and complications lead to more costly acute illness, disability, and premature death.

Primary care providers feel the support of a multi-disciplinary team and can spend the time to address each complex patient’s needs.

Anoop Raman, MD, MBA, a front-line family physician and Chief Medical Officer of Complex Care at AbsoluteCare, is steeped in the High-Need High-Cost model. He provided the following insights on what is required for success, for patients and provider, in his work with the new model.

“When we think about Population Health, we are very intentional about what those two words mean to us: Population—what are the core and unique needs of the population we serve? Health—what is the model of care needed to address those unique needs?

AbsoluteCare serves a unique population. We exclusively serve the most medically complex, socially vulnerable patients—a population other organizations might consider adverse selection. Based on historic trends and predictive analytics, we collaborate with our payers to identify our population. Our patients are then invited by their insurance company to join.

It is essentially concierge care for the sickest, instead of the richest. Our members have access to free transportation to their (longer than average/30 minute) primary care appointment; we have lab, x-ray, full pharmacy, infusion services onsite; and we have a robust interdisciplinary team comprised of registered nurses, licensed social workers, behavioral health consultants, and community health workers to provide whole person care. For us, this is what health equity looks like—matching intensity of need with intensity of care.”

The high-need, high-cost models represent an exciting transformation of primary care. This strategy is improving the health and experience for our most complex patients, while confronting the rising cost of health care.

References:

1. Centers for Medicare & Medicaid Services. National health expenditure data. Updated December 15, 2021. Accessed May 11, 2022. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
2. Agency for Heathcare Research and Quality. Statistical Brief #449: the concentration and persistence in the level of health expenditures over time: Estimates for the U. population, 2011-2012. 2014. Accessed May 11, 2022. https://www.meps.ahrq.gov/data_files/publications/st449/stat449.shtml
3. American Hospital Association. Improving care for high-need, high-cost patients. 2022. Accessed May 11, 2022. https://www.aha.org/ahahret-guides/2017-10-03-improving-care-high-need-high-cost-patients
4. Gawande A. The Hot Spotters: can we lower medical costs by giving the neediest patients better care? January 16, 2011. Accessed May 11, 2022. https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters
5. Finkelstein A, Zhou A, Taubman S, Doyle J. Health care hotspotting—a randomized, controlled trial. N Engl J Med. 2020;382:152-162. doi:10.1056/NEJMsa1906848