Identifying High-Cost Patients for Care Management

The fact that a small percentage of the population accounts for roughly half of healthcare spending in the United States is not new information. Now a new white paper from the Health Care Transformation Task Force has taken a look at what healthcare systems can do to identify these individuals in order to better manage their care and lower spending.

The white paper defines the different types of high-cost patients, outlines their clinical characteristics, and describes methods to stratify high-cost patients for care management.

“This paper provides a starting point for payer-and provider-led efforts to identify high cost individuals who are most likely to benefit from care management programs and approaches,” the authors wrote. “Changing overall clinical, utilization, and cost outcomes for the entire population may best be accomplished by intervening with the small number of patients with highest need and highest cost.”

The authors of the paper broke the high-cost population into 3 subgroups: patients with advanced illness, patients with persistent high-spending patterns, and patients without persistent high spending. The last group is the only one that is not a good candidate for care management.

Patients with advanced illness are often nearing the end of life. Care management strategies include informed choice and optimizing the use of hospice and other palliative care services. Not only do most patients prefer to die at home, but redirecting care from the hospital has the potential for significant savings, according to the Task Force.

Patients with persistent high-spending patterns are often characterized by multiple chronic conditions and face psycho-social barriers to care. Case management for these patients, identified by claims based algorithm, can also result in substantial cost reduction.

In comparison, the third group of patients cannot be targeted proactively because their increased costs are due to a sudden event. Once the condition is resolved, the costs decrease without intervention.

“Strategies to improve care for patients with advanced illness or persistently high costs are challenging to implement, but several viable innovative models exist,” the authors wrote.

The Task Force’s next white paper will highlight successful interventions and strategies for building programs that can be scaled in diverse clinical and cultural settings.