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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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1

INTRODUCTION AND OVERVIEW

The exceptionally high expenditures associated with providing care for a relatively small but growing number of individuals with significant medical needs disproportionately drive the escalating cost of medical care in the United States. This population of high-need individuals includes an increasingly heterogeneous group of people with multiple chronic diseases, members of an aging population, and patients with varying levels of medical, functional, social, and behavioral complexity. Today, 1 percent of patients account for more than 20 percent of health care expenditures, and 5 percent account for nearly half of the nation’s spending on health care (Mitchell, 2016). Improving care management for this population while balancing quality and associated costs is at the forefront of national health care goals, and reaching this particular goal will require the active involvement of a broad range of stakeholders at multiple levels. Health care systems have implemented several successful strategies with the hope of improving health outcomes, improving the patient experience, and lowering costs, but a “best practice” for high-need patient management has proven elusive; the majority of care remains fragmented, uncoordinated, reactive, and often poorly matched to individuals’ circumstances. The nation needs a better understanding of how to best utilize its resources to care for this growing population.

To advance insights and perspectives on how to better manage the care of high-need patients and to stimulate actions on opportunities for improving outcomes and reducing the costs of health care for these vulnerable populations, the National Academy of Medicine (NAM), through its Leadership Consortium for a Value & Science-Driven Health System (the Leadership Consortium), in partnership with the Harvard T.H. Chan School of Public Health (HSPH), the Bipartisan Policy Center (BPC), The Commonwealth Fund, and the Peterson Center on Healthcare—which funded this initiative—has undertaken a collaborative assessment on strategies for better serving high-need patients. The project activities were overseen by an independent planning committee and included (1) planning three workshops to explore the state of knowledge and action;

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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(2) conducting a literature review of the key studies on the care of high-need patients; and (3) synthesizing the work and proceedings that reflected critical needs and common themes on effective approaches, care models, and possible policy actions to address those needs. This publication synthesizes information and insights gleaned from the workshop presentations and discussions, as well as concurrent and supplemental work led by the partnering organizations, the workshop planning committee, and other external experts and stakeholders, to move the field forward.

PARTNER ORGANIZATIONS

The five-way partnership involving the Leadership Consortium, the HSPH, the BPC, the Peterson Center on Healthcare, and The Commonwealth Fund has driven this project, with each partner taking on a specific role. The Peterson Center on Healthcare is dedicated to identifying proven solutions that improve care quality, lower costs, and accelerate the adoption of these solutions on a national level. With the aim of identifying programs that successfully serve the growing number of high-need individuals and potential policy solutions to bring these models to scale, the Peterson Center initiated and provided support for the contributions of the NAM, the BPC, and the HSPH.

The BPC examined different policy approaches that might address barriers and accelerate the adoption of proven models for improving care and reducing costs for high-need patients. Its work culminated in a report that was presented at the final workshop and contained draft policy recommendations and areas of opportunity to improve care and outcomes for high-need patients (Hayes et al., 2016a). These recommendations aimed to better align financial incentives, specifically those targeting care for dual-eligible2 high-need patients.

HSPH’s role in this project has been to provide an analysis of data to define both clinically and socially meaningful segments of this heterogeneous group of people as a means of identifying subgroups that might benefit from specific types of programs (Joynt et al., 2017). This analysis addressed three key questions relevant to controllable costs:

  • What are the specific characteristics associated with high-need, high-cost patients within these segments?

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2 Dual-eligible patients are low-income Medicare beneficiaries who are eligible for Medicare and Medicaid.

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
  • How do utilization patterns differ between these segments and within the segments?
  • What proportion of the spending and utilization might be reduced for each segment?

HSPH’s project team has attempted to identify characteristics of providers and health systems that are more effective at caring for high-need, high-cost patients and reducing the costs associated with preventable health care issues. The project team, with the help of The Commonwealth Fund, examined data from the Medicare population and a set of commercial patients. The team has also worked with colleagues at the Peterson Center on Healthcare to examine data on the dual-eligible population.

The Commonwealth Fund has placed a primary emphasis on these issues and has served as a strategic adviser and contributor throughout the initiative, leveraging its extensive portfolio of work focused on improving care for high-need, high-cost patients. A research and funding institution that aims to promote a high-performing health care system, particularly for the most vulnerable, The Commonwealth Fund is also part of a consortium of five national foundations along with the John A. Hartford Foundation, the Robert Wood Johnson Foundation, the Peterson Center on Healthcare, and The SCAN Foundation—all focused on furthering efforts to improve care for high-need patients. The collaboration works to develop resources to understand the diverse high-need population, to identify evidence-based programs that offer high-quality integrated care at a lower cost, and to accelerate the adoption of these programs nationally.3

THE NATIONAL ACADEMY OF MEDICINE

As the convening body for this initiative, the National Academy of Medicine—through its Leadership Consortium for a Value & Science-Driven Health System—brought together experts and stakeholders to reflect upon the key issues for improving care for high-need patients, synthesize the information and insights gathered, and summarize the presentations, discussions, and literature for publication.

Broadly, the Leadership Consortium convenes national experts and executive-level leaders from key stakeholder sectors for collaborative activities to

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3 For more information on this consortium, see www.commonwealthfund.org/publications/newsletters/the-commonwealth-fund-connection/2016/aug/aug-2-2016/whats-new/five-health-care-foundations (accessed December 21, 2016). For an example of resources pulled together, see “the Playbook,” at http://www.bettercareplaybook.org (accessed December 21, 2016).

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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foster progress toward a continuously learning health system in which science, informatics, incentives, and culture are aligned for enduring improvement and innovation; best practices are seamlessly embedded in the care process; patients and families are active participants in all elements; and new knowledge is captured as an integral by-product of the care experience. Priorities in this respect include advancing the development of a fully interoperable digital infrastructure, the application of new clinical research approaches, and a culture of transparency on outcomes and cost.

Participants in the Leadership Consortium have set a goal that, by 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and reflect the best available evidence. The Leadership Consortium’s approach to meeting this goal is to serve as a forum to facilitate the collaborative assessment and action around issues central to achieving its vision and goal. To address the challenges of improving both evidence development and evidence application, as well as improving the capacity to advance progress on each of those dimensions, Leadership Consortium members (all leaders in their fields) work with their colleagues to identify the issues not being adequately addressed, the nature of the barriers and possible solutions, and the priorities for action. They then work to marshal the resources of the sectors represented on the Leadership Consortium to work for sustained public-private cooperation for change.

A common commitment to certain principles and priorities guides the activities of the Leadership Consortium and its members. These include the commitment to the right health care for each person; putting the best evidence into practice; establishing the effectiveness, efficiency, and safety of medical care delivered; building assessment and accountability into care; advancing clinical data as a public resource for health improvement; shared responsibility distributed equitably across stakeholders, both public and private; collaborative stakeholder involvement in priority setting; transparency in executing activities and reporting results; and individual stakeholder perspectives subjugated to the common good.

SCOPE AND ACTIVITIES

The independent planning committee organized the three workshops (see Appendix B for the agendas) in accordance with the procedures of the National Academies of Sciences, Engineering, and Medicine. The planning committee’s members were Peter V. Long, Chair (Blue Shield of California Foundation), Melinda K. Abrams (The Commonwealth Fund), Gerard F. Anderson (Johns

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

Hopkins Bloomberg School of Public Health), Tim Engelhardt (Centers for Medicare & Medicaid Services), Jose Figueroa (Harvard Medical School), Katherine Hayes (Bipartisan Policy Center), Frederick Isasi (National Governors Association), Ashish K. Jha (Harvard T.H. Chan School of Public Health), David Meyers (Agency for Healthcare Research and Quality), Arnold S. Milstein (Stanford University), Diane Stewart (Pacific Business Group on Health), and Sandra Wilkniss (National Governors Association).

The workshops brought together national experts and stakeholders to explore commonalities and differences among the subpopulations of high-need patients, to consider the lessons learned from targeted intervention activities, to discuss and inform the approach of the ongoing study by the HSPH on the high-cost Medicare population, and to review policy issues and options, including those suggested by the BPC.

The first workshop, held in July 2015, laid the groundwork for this project and the subsequent workshops. The presentations and discussions identified the key characteristics of high-need patient populations and subgroups of these heterogeneous populations that offer the greatest opportunity for impact. This workshop also examined the factors that are most important in determining which care models are most effective for particular subgroups of high-need patients; the types of active care coordination and providers of social and behavioral health services and supports in different circumstances; and the lessons from past experiences with high-need patients that can inform efforts to spread and scale successful care models.

The second workshop, convened in January 2016, built on the insights from the first workshop and further explored specific issues. The presentations and discussions in the second workshop focused on the use of a patient segmentation strategy to inform which care models are most appropriate for specific subpopulation of high-need patients. They also reviewed sources of data to drive segmentation strategies, efforts to build a taxonomy of high-need patients, and specific design elements of a successful care model. Sessions at this workshop also discussed specific replication strategies to spread and scale those models, the barriers to scaling new delivery models, and essential elements for a policy framework that could mitigate those barriers.

The third workshop, held in October 2016, discussed the implications of the findings of HSPH’s study and the policy strategies identified by the BPC. The presentations and discussions at the third workshop examined tools to improve care delivery for high-need patients, including a taxonomy that matches patient needs to care models with the most potential to improve outcomes and lower costs of caring for high-need patients. This workshop also discussed policy-level

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×

approaches to support and accelerate the spread and scale of effective care models. An independent rapporteur prepared factual summaries of what occurred at the workshops. Statements, recommendations, and opinions expressed at the workshops were those of individual presenters and participants and have not been endorsed or validated by the NAM.

In addition to the three workshops, the planning committee initiated several important supplementary activities. A taxonomy workgroup reviewed existing approaches and developed guidance on adaptation and application of a taxonomy in practice. Chapter 3 includes the findings from the workgroup’s efforts and supporting research. A review of care models examined in the literature identified promising types of care models and key attributes for success. This review informs a four-part framework described in Chapter 4, as well as how successful care models might map to different high-need patient segments. A subgroup of the planning committee also examined policy options most likely to reduce the barriers to the spread and scale of successful models. Those deliberations, together with the work of the BPC and others, provided much of the content for Chapter 5.

RECURRING THEMES

Informed by discussions, presentations, and concurrent work throughout the course of the project period, this publication reports and reflects on the following issues: (1) key characteristics of high-need patients; (2) the use of a patient categorization scheme—or a taxonomy—as a tool to inform and target care; (3) promising care models and attributes to better serve this patient population, as well as insights on “matching” these models to specific patient groups; and (4) areas of opportunity for policy-level action to support the spread and scale of evidence-based programs. Each of the main chapters begins with a fictional patient vignette highlighting a main point discussed in the chapter. The publication concludes by exploring common themes and opportunities for action in the field.

Recurring themes throughout the initiative include those related to:

  • Functional status. Functional status is a central determinant of the nature and level of health care needs.
  • Cost. Patients with complex needs are often high-cost patients, but some high-cost patients do not necessarily have complex needs—for example, those with conditions effectively treated by high-cost interventions.
  • Social circumstances. Accommodation of social circumstances is key to addressing individuals with high needs.
Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
×
  • Social services. Improving care for high-need patients usually requires engaging services outside of the care system and creating patient- and care-partner-specific care plans.
  • Service linkages. Coordination of care is critical for high-need patients, and success depends on alignment and cooperation between the health care system and services delivered through social, economic, and behavioral programs.
  • Targeting specificity and timeliness. Health care systems with effective and efficient approaches to sustaining and improving levels of function of high-need patients are those most deliberate and active in identifying and targeting needs early on.
  • Payment alignment. Payment models segmented according to individual services offer incentives counter to successful models of care for high-need patients, including those of certain Medicare and Medicaid payment policies.
  • Duration. The nature and level of needs can change over time. A significant number of high-need patients are only transiently high-need.
  • Variability. High-need patients are heterogeneous and no single care model can provide all the services required by high-need patients; relevant approaches must therefore be guided by a taxonomy that matches intervention options with the specific needs of different categories of high-need patients.

REFERENCES

Hayes, K., G. W. Hoadland, N. Lopez, M. Workman, P. Fise, K. Taylor, R. Meltzer, and S. Seong. 2016. Delivery system reform: Improving care for individuals dually eligible for Medicare and Medicaid. Washington, DC: Bipartisan Policy Center.

Joynt, K. E., J. F. Figueroa, N. Beaulieu, R. C. Wild, E. J. Orav, and A. K. Jha. 2017. Segmenting high-cost Medicare patients into potentially actionable cohorts. Healthc (Amst) 5(1-2):62-67.

Mitchell, E. M. 2016. Statistical Brief #497: Concentration of Health Expenditures in the US Civilian 298 Noninstitutionalized Population, 2014. Agency for Healthcare Research and Quality.

Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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Suggested Citation:"1 Introduction and Overview." National Academy of Medicine. 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: The National Academies Press. doi: 10.17226/27115.
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To advance insights and perspectives on how to better manage the care of the high-need patient population, the National Academy of Medicine, with guidance from an expert planning committee, was tasked with convening three workshops held between July 2015 and October 2016. The resulting special publication, Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health, summarizes the presentations, discussions, and relevant literature.

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