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NOTICE: This publication has undergone peer review according to procedures established by the National Academy of Medicine (NAM). Publication by the NAM signifies that it is the product of a carefully considered process and is a useful contribution worthy of public attention, but does not represent formal endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual authors and do not represent formal consensus positions of the authors’ organizations; the NAM; or the National Academies of Sciences, Engineering, and Medicine.

Support for this activity was provided by the Peterson Center on Healthcare, which is dedicated to identifying proven solutions that improve care quality, lower costs, and accelerate the adoption of these solutions on a national level.

Library of Congress Cataloging-in-Publication Data

Names: Long, Peter (Peter V.), editor. | National Academy of Medicine (U.S.), publisher. | Leadership Consortium for a Value & Science-Driven Health System, issuing body. | Models of Care for High-Need Patients (Workshop) (2015-2016 : Washington, D.C.)

Title: Effective care for high-need patients : opportunities for improving outcomes, value, and health / Peter Long, Melinda Abrams, Arnold Milstein, Gerald Anderson, Katherine Lewis Apton, Maria Lund Dahlberg, and Danielle Whicher, editors ; Leadership Consortium for a Value & Science-Driven Health System.

Description: Washington, DC : National Academy Of Medicine, [2017] | Report on issues discussed over the course of 3 public workshops held between July 2015 and October 2016 at the National Academy of Medicine, Washington, DC. | Includes bibliographical references.

Identifiers: LCCN 2017041343 (print) | LCCN 2017042253 (ebook) | ISBN 9781947103078 (Ebook) | ISBN 9781947103061 (pbk.)

Subjects: | MESH: Health Services Needs and Demand | Health Services--utilization | Delivery of Health Care--utilization | Delivery of Health Care--economics | Patient Care Management--economics | United States | Congresses

Classification: LCC RA425 (ebook) | LCC RA425 (print) | NLM W 84 AA1 | DDC 362.1--dc23

LC record available at https://lccn.loc.gov/2017041343

Copyright 2017 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Suggested citation: Long, P., M. Abrams, A. Milstein, G. Anderson, K. Lewis Apton, M. Lund Dahlberg, and D. Whicher, Editors. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: National Academy of Medicine.

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PLANNING COMMITTEE FOR THE WORKSHOP SERIES ON MODELS OF CARE FOR HIGH-NEED PATIENTS

NAM Staff

Development of this publication was facilitated by contributions of the following NAM staff, under the guidance of Michael McGinnis, NAM Leonard D. Schaeffer Executive Officer and Executive Director of the Leadership Consortium for a Value & Science-Driven Health System:

Consultant

TAXONOMY WORKGROUP

MELINDA K. ABRAMS, Vice President, Delivery System Reform, The Commonwealth Fund

GERARD F. ANDERSON, Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health

MELINDA J. BEEUWKES BUNTIN, Chair, Department of Health Policy, Vanderbilt University School of Medicine

DAVE A. CHOKSHI, Assistant Vice President, New York City Health and Hospitals Corporation

HENRY CLAYPOOL, Policy Director, Community Living Policy Center, University of California San Francisco

DAVID A. DORR, Professor & Vice Chair, Medical Informatics, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University

JOSE FIGUEROA, Instructor of Medicine, Harvard Medical School; Associate Physician, Brigham and Women’s Hospital

ASHISH K. JHA, K.T. Li Professor of International Health and Health Policy, Director, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health

DAVID LABBY, Founding Chief Medical Officer & Health Strategy Adviser, Health Share of Oregon

PRABHJOT SINGH, Director, Arnhold Institute for Global Health, Mount Sinai Health System

POLICY WORKGROUP

GERARD F. ANDERSON, Director, Center for Hospital Finance and Management, Johns Hopkins Bloomberg School of Public Health

TIM ENGELHARDT, Director, Federal Coordinated Health Care Office, Centers for Medicare & Medicaid Services

KATHERINE HAYES, Director, Health Policy, Bipartisan Policy Center

SANDRA WILKNISS, Program Director, Health Division, National Governors Association

REVIEWERS

This special publication has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with review procedures established by the NAM. We wish to thank the following individuals for their review of this publication:

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the content of this publication, nor did they see the final draft before it was published. Review of this publication was overseen by Danielle Whicher, senior program officer, NAM; Gwen Hughes, senior program assistant, NAM; and Michael McGinnis, Leonard D. Schaeffer Executive Officer, NAM. Responsibility for the final content of this publication rests entirely with the authors and the NAM.

PREFACE

The National Academy of Medicine’s Leadership Consortium for a Value & Science-Driven Health System provides a trusted venue for national leaders in health and health care to work cooperatively toward effective, innovative care that consistently adds value to patients and society. Consortium members are leaders from stakeholder communities brought together by their common commitment to steward advances in science, value, and culture necessary for a health system that continuously learns and improves in fostering healthier people.

It has been known for some time that a small percentage of patients with complex health and social needs use a disproportionate share of medical care at significant cost to them, the healthcare system, and broader society. There is also substantial evidence that the standard of care provided to these individuals, while costly, often does not meet their expectations. That said, there exists a number of successful programs and models in health systems and communities across the country that are providing excellent care and producing positive results. To date, they have remained positive exceptions to the norm rather than become the standard of care. Beyond the inherent challenges of scaling and spreading promising care models, there is a growing recognition that some federal and state health policies and payment models inhibit rather than facilitate the delivery of more effective and lower cost care and services for high-need patients.

NAM hosted three public workshops exploring high-need patients in more depth to inform future policy and practice. Through our inquiry, we found that bold policy action and care delivery reform is needed to improve care for high-need patients and reduce costs. The high-need patient population is diverse, complex, expensive, and dynamic. Addressing their needs will require the appropriate balance between standardized and customized approaches to care. Segmenting high-need patients into smaller homogeneous subgroups using a “taxonomy” represents one promising tool to inform and target care and should be rapidly tested in real-world settings in conjunction with care models that have been shown to work. It is clear that effective tools, care models, and policies must extend beyond strictly medical approaches to address social and behavioral factors. In order to be actionable, policy solutions must account for

CONTENTS

Acronyms and Abbreviations

Summary

Key Characteristics of High-Need Patients

The Patient Taxonomy and Implications for Care Delivery

Care Models that Deliver

Policy to Support the Spread and Scale of Care Models

Common Themes and Opportunities for Action

References

1 Introduction and Overview

Partner Organizations

The National Academy of Medicine

Scope and Activities

Recurring Themes

References

2 Key Characteristics of High-Need Patients

Identifying High-Need Patient Populations

The Overlap of High-Need and High-Cost Definitions

The Impact of Being a High-Need Patient

References

3 Patient Taxonomy and Implications for Care Delivery

Purpose and Operation of Patient Segmentation

Developing a Taxonomy

Identifying Segments

A Conceptual “Starter”Taxonomy

High-Impact Social Risk and Behavioral Health Variables

Advancing the Use of a Taxonomy

References

4 Care Models That Deliver

Characterizing Successful Models

Focus of Service Setting

Care and Condition Attributes

Delivery Features

Organizational Culture

Care Models that Deliver and the Patient Taxonomy

Denver Health:A“Real-World”Application

References

5 Policy to Support the Spread and Scale of Care Models

Spreading and Scaling Successful Care Models

Integration of Social Supports and Medical Care

Expand and Align Payment Policies

Workforce For Comprehensive Health Care

Reexamine Quality Measurement

Improve Data Infrastructure

References

6 Common Themes and Opportunities for Action

Main Themes and Lessons

Opportunities for Stakeholder Action

Conclusion

References

APPENDIXES

A Care Model Case Studies

B Workshop Agendas

C Workshop Participants

D Biographical Sketche

Planning Committee Biographies

Taxonomy Workgroup Biographies

BOXES, FIGURES, AND TABLES

Boxes

S–1 Care and Condition Attributes of Successful Care Models

S–2 Delivery Features of Successful Care Models

4–1 Service Setting and Focus of Successful Care Models

4–2 Care and Condition Attributes of Successful Care Models

4–3 Delivery Features of Successful Care Models

4–4 Organizational Culture of Successful Care Models

5–1 Selected Excerpts from the Bipartisan Policy Center’s Recommendations to Align Programs and Integrate Care for Dual-Eligible Beneficiaries

Figures

S–1 Distribution of personal health care spending in the US civilian noninstitutionalized population, 2014.

S–2 A conceptual model of a starter taxonomy for high-need patients.

S–3 A sample of 14 care models which have evidence of success, matched to the six population segments identified in the taxonomy showing that each segment has been matched to at least one program. A subset of these care models also targets social and/or behavioral risk factors faced by high-need patients and is marked with an (*).

2–1 Distribution of personal health care spending in the US civilian noninstitutionalized population, 2014.

2–2 Mean number of chronic conditions among three groups of Massachusetts residents.

2–3 Mean number of frailty indicators among three groups of Massachusetts residents.

2–4 High-need adults had higher spending on health care than did those with three or more chronic conditions without functional limitations.

2–5 High-need adults have more emergency department visits and hospital stays.

2–6 Demographic characteristics of high-need adults.

3–1 A conceptual model of a starter taxonomy for high-need patients.

3–2 A framework for health with all of the factors that would go into an ideal taxonomy.

3–3 Patient categories by payer group: proportion of all high-cost patients in the non-Medicare under-65 population (blue), Medicare population (brown), and dual-eligible population (green).

3–4 Preventable spending by patient group in the Medicare population.

3–5 High-cost Medicare patients’ distributional mean spending by patient category.

4–1 Variations in the needs of dual-eligible individuals.

4–2 A sample of 14 care models which have evidence of success, matched to the six population segments identified in the taxonomy showing that each segment has been matched to at least one program. A subset of these care models also targets social and/or behavioral risk factors faced by high-need patients and is marked with an (*).

4–3 Denver Health’s use of Clinical Risk Groups to assign patients to care programs.

Tables

S–1 Clinical Group Features

2–1 Complex and Noncomplex Chronic Conditions

3–1 Clinical Group Features

3–2 High-Impact Social Variables

3–3 High-Impact Behavioral Variables

ACRONYMS AND ABBREVIATIONS