We’re Getting to Know What the High-Needs Patient Population Looks Like—and Seeing Clear Gaps

May 25, 2017
What do we know about the patients with the highest and most complex needs, as the healthcare system evolves forward around population health and care management—and what do we need to know? Some recent research and analyses shed light

There’s so much going on right now around population health management and care management, it really is worthwhile to pause for a moment and think about a key question: what do we know about patients with high and complex needs—the patients who are going to be the clear focus of many of the efforts going forward in the U.S. healthcare system? Let’s take a step back and consider.

To begin, the announcement a week ago that the federal Centers for Medicare and Medicaid Services (CMS) was expanding the map of regions open to participation in its Comprehensive Primary Care Plus program, or CPCP+, was yet another signal that federal officials are looking to expand the ways in which the federal government can help providers provide higher-quality, more efficient patient care in a primary care setting.

As I wrote in a blog on the topic earlier this week, the CPC+ program’s core payment elements—including paying a care management fee to primary care practices to account for the intensity of care management services required for the specific population of individual practices; the prospective payment of performance-based incentive payments; and a shift in how fee-for-service payments are made, to account for participation in the CPC+ Program—are elements in CPC+ that build on the original Comprehensive Primary Care Program, and  that are intended to incent improved care management and patient outcomes.

And, in that blog, I wrote this: “What CPC program participants have been learning, and what CPC+ program participants will be learning going forward, could help reshape care delivery at the primary care level—the potential here is enormous. And healthcare IT leaders will need to be broadly and deeply involved at all levels, working as a team with clinician leaders and frontline clinicians to get it done. And, given the five-year framework of CPC+, you can bet we’ll be hearing about developments in this critical initiative going forward. Meanwhile, there’s not a moment to waste for the healthcare IT leaders and professionals working with the leaders of primary care practices involved in CPC+, in order to make rapid advances to show that it can be done. I’m excited by the prospects, and will be watching the forward evolution of this program very closely, in the coming months and years.”

I also noted in a blog earlier this month the results of a recent KPMG study that found that both provider and payer organizations are gaining ground in effectively using population health IT infrastructures and platforms to care-manage patients. As I noted in the May 9 blog, “According to that survey, provider and health plan leaders are making progress in key areas. As stated in the consulting firm’s Jan. 23 press release, ‘In the survey, 44 percent of respondents at payer and provider organizations found that they have a population health platform in place that is being ‘utilized efficiently and effectively.’ Another 24 percent are in the process of implementing a population health program within the next three years. Only 10 percent said they have no plans to implement a population health platform and another 21 percent of respondents said their organization doesn’t require a population health platform.’”

In that blog, I further noted that KPMG’s researchers had found that “The biggest individual barrier to implementing a population health program is aggregating and standardizing information from multiple sources, 30 percent of respondents said. Stakeholder adoption (10 percent) and integrating with clinical work flows (10 percent) were cited as additional barriers. Another 34 percent cited ‘all of the above,’ which includes those barriers, as well as enabling patient engagement, funding investments, and selecting appropriate vendors as additional challenges.”

I’ve recently also written a blog noting what’s been learned at one innovative organization, Massachusetts General Hospital in Boston, whose leaders had participated in the Medicare Care Management for High Cost Beneficiaries Demonstration and had developed an intensive care management program, in what turned out to be a test run for what later became the Pioneer ACO Program. Writing in the May issue of Health Affairs, a large team of researchers led by John Hsu found, in examining Mass General’s program, that “The care management program (the ACO’s primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent.”

Looking at high-need patients—and the gaps in their care management

All of these learnings and so many more will be needed going forward to achieve outcomes breakthroughs among patients with high and complex needs, as an article published on the website of the Commonwealth Fund in December makes clear. In the article, entitled “As New Survey Describes Scope of Problem, Five National Health Care Foundations Identify Promising Approaches for Treating Patients with Complex Needs,” published on the organization’s website, Commonwealth Fund leaders note that “A new nationwide survey of patients with complex medical needs shows that the health care system is failing them, with these individuals having far more unmet behavioral health and social service challenges than other adults. While nearly all of the high-need patients surveyed have consistent access to health care (95 percent),” the report notes, “they nevertheless struggle to get the coordinated medical, behavioral, and social services they need to stay well and avoid costly hospital visits. Specifically, they had limited access to: care coordinators, assistance in managing functional limitations, emotional counseling, and transportation services.”

In this context, Commonwealth Fund researchers defined high-needs patients as “patients with clinically complex conditions, cognitive or physical limitations, or behavioral health problems,” including “people with two or more major chronic conditions like diabetes or heart failure,” some of them with “unmet social needs that may exacerbate their medical conditions.” In any given year, Commonwealth Fund researchers note, “Ten percent of patients account for 65 percent of the nation’s health care expenditures.”

Importantly, the article notes, “The Commonwealth Fund survey of 3,009 adults (1,805 of whom are high-need) is being released as five national health care foundations—The John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, The SCAN Foundation, and The Commonwealth Fund—launch a new online resource to help health system leaders and insurers improve care for patients with complex medical and social needs.”

In that regard, the Commonwealth Fund’s survey confirms some of the things already known about the high-needs population, but that deserved being affirmed by the survey. Among them:

Ø  Compared with the general population, the high-need population is older, has lower levels of education and income, and includes more women and African-Americans.

Ø  High-need patients use more health care services than other adults, as has been reported in previous analyses.

Ø  Nearly half (48 percent) of high-need respondents were hospitalized overnight in the past two years.

Ø  A similar percentage (47 percent) went to the emergency department multiple times in the past two years.

Ø  Approximately one of five (19 percent) used the emergency department for a condition that could have been treated in a doctor’s office or a clinic.

Ø  Adults with high medical needs often have unmet emotional and social needs. The survey results indicate that this group is more likely than the general population to report experiencing emotional distress that was difficult to cope with on their own in the past two years.

Ø  Indeed, 37 percent of high-need respondents reported often feeling socially isolated, including lacking companionship, feeling left out, or feeling lonely or isolated from others, compared with 15 percent of other adults.

Ø  Almost two-thirds (62 percent) of high-need respondents report stress or worry about material hardships, such as being unable to pay for housing, utilities, or nutritious meals, compared to only one-third of other adults (32 percent).

Ø  Furthermore, six of 10 (59 percent) high-need adults report being somewhat or very concerned about being a burden to family or friends.

Ø  More than two-fifths (44 percent) of high-need patients reported delaying care in the past year because of an access problem such as lack of transportation to the doctor’s office, limited office hours, or an inability to get an appointment quickly enough.

Ø  Nearly one-quarter (22 percent) of high-need respondents specifically reported a lack of transportation as a reason for delaying care, compared with only 4 percent of other adults.

Ø  Three of 10 (29 percent) of high-need respondents reported delaying care specifically as a result of not being able to get an appointment soon enough with their regular provider.

Interestingly, nearly 95 percent of high-need survey respondents reported having a regular physician or place of care; yet only two-thirds of adults (65 percent of high-need and 68 percent of other adults) report being able to get an answer the same day when they contact their doctor’s office with a medical question, in line with similar analyses.7 In particular, high-need respondents report difficulty being able to get after-hours medical care on weekends, evenings, or holidays. And only one-third (35 percent) of high-need respondents reported it was somewhat or very easy to get medical care after-hours without going to the emergency room, compared with more than half (53 percent) of other adults.

All of these statistics coming out of the Commonwealth Fund survey are confirming a lot of what we already knew about high-need patients—a group that includes both patients with two or more chronic conditions, and also patients with clinically complex conditions, or with both physical and behavioral issues, or with cognitive or physical limitations.

Here’s the thing: what the leaders of patient care organizations, and health plans, who are building infrastructures for population health management and care management, need to do, clearly, is to work along several dimensions at once. There is so much beyond the purely clinical or medical aspects of care management, and the results of this Commonwealth Fund survey, as well as the analyses I’ve mentioned above, speak to the complexity, the challenges—and yes, the opportunities—inherent in developing robust, effective care management programs for patients with high needs.

What’s more, I see IT and analytics as being incredibly important in all this, and at every level of activity. I’ve been involved in many discussions in the past year or two with industry leaders, around this broad subject. Everyone agrees that we need to get far more demographic, socioeconomic, and other data, around covered populations. So very many of the factors that ultimately impact patient outcomes aren’t strictly medical at all. I remember writing an article 20 years ago now, in which I was researching advances in care management on the part of health plans, for their dual eligible members—individuals qualified to receive healthcare coverage under both Medicare and Medicaid. Those individuals are by definition older and poorer; and they often have very complex personal situations. One health plan whose care management leaders I interviewed, had done things like ensuring that case managers went to dual-eligible plan members’ homes in order to see what their home environments were like. In a few cases, the health plan ended up purchasing handrails for their houses. It was really a simple decision to make, the chief medical officer of the health plan told me. When you look at the cost of purchasing the  materials and hammering handrails into the walls of a plan member’s hallway in their home--$100, say—that cost is infinitesimally small when compared to the cost to the health plan of that plan member’s falling in her/his home, breaking his/her hip, and going into a whole different set of care delivery and care management processes. It’s the right thing to do, too, of course.

But the U.S. healthcare system, which has been for its entire history deeply and broadly fragmented, along so many dimensions, is only beginning now to catch up to these realities. And providers are being pushed forward by their taking on risk-based contracts, which are compelling them forward to expand what had been the limits of care delivery and care management.

Frankly, it’s absolutely time—some would even say, past time—that the U.S. healthcare system is moving forward towards more comprehensive approaches to care management and population health management. And for that, we really can thank federal healthcare officials, who have been using various provisions within the Affordable Care Act to compel readmissions reduction, encourage the development of affordable care organizations and bundled-payment contracting, and shepherd forward comprehensive primary care.

The time is now—and healthcare IT leaders’ efforts will be essential, in depth and in breadth, to help create the IT and analytics infrastructures to support all of this work. It will be  bracing time for CIOs, CMIOs, and everyone who works with them—but also a very exciting one. And in the next few years, all of these kinds of initiatives will accelerate forward. But a key element in all of this, not surprisingly, will be getting to know patients with high and complex needs, in greater depth and breadth—that element will prove absolutely essential to every successful effort going forward.

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