It is common knowledge that U.S. health care costs are concentrated among a small proportion of patients, with 5% of patients accounting for 50% of health care spending.1 This is a clinically and socially heterogeneous population for whom functional limitations (e.g., the ability to perform daily activities such as bathing, dressing, or preparing food) and behavioral health needs (e.g., treatment for mental health conditions and/or substance use disorders) play a major role in their health care utilization and expenditures.2 These high-need, high-cost adults tend to be older (over 65), have low socioeconomic status, and have public insurance.2 Moreover, a recent survey by the Commonwealth Fund found that high-need, high-cost adults who report feeling socially isolated are more likely to have mental, emotional, and financial issues and are less likely to receive timely, good-quality care than are those who do not report feeling alone.3
Health care delivery systems, including academic medical centers (AMCs), are increasingly focused on improving care for such vulnerable, high-need, high-cost patients, in part because value-based payment models, which include a range of payment approaches and incentives such as capitation, shared savings, or performance incentives, offer the promise of a financial return, or the avoidance of losses, for doing so. One approach for accomplishing this is the accountable care organization (ACO) model, which forces leaders to address cost drivers, such as avoidable utilization for patients with complex needs. Many AMCs have shown interest in the ACO model, as seen by the fact that 14% of all ACOs are Association of American Medical Colleges (AAMC) members.4 Recent research finds that AMCs generally achieve better mortality outcomes than nonteaching hospitals.5 To build on this quality advantage while also realizing cost savings in any value-based payment model, AMCs will need to redesign care for complex patients, as some have already done. Below are six key features of programs that have proven results for improving care for this high-need, high-cost population.
Program Features Adopted by AMCs
AMCs and other providers that have participated in Medicare and Medicaid demonstrations and value-based payment programs have valuable insights to offer about the key features of successful and promising programs for high-need, high-cost patients.6–8 These field-tested practices include (1) targeting interventions to those patients who are most likely to benefit, (2) comprehensively assessing patients’ needs, (3) employing trained care managers to facilitate coordination among care team members, (4) implementing supportive health information technology, (5) promoting patient and caregiver engagement, and (6) partnering with social service providers to address patients’ nonclinical needs.
Targeting interventions to those patients who are most likely to benefit
Care management yields a return on investment only when it reduces service costs by more than it costs to run the program. Washington University in St. Louis learned this lesson through its participation in Medicare’s Coordinated Care demonstration, as it achieved net savings only after reconfiguring its care coordination program to focus on meeting the needs of higher-risk chronically ill patients. They did so by better assessing patients’ health risks, increasing in-person contacts with higher-risk patients by local care managers, and assigning the oversight of patients at lower risk to care manager assistants.9
Comprehensively assessing patients’ needs
The Geriatric Resources for Assessment and Care of Elders (GRACE) model, developed at the Indiana University School of Medicine, offers patients a comprehensive in-home assessment by a nurse practitioner and social worker team, who document information such as history of falls, housing status, depressive symptoms, and functional limitations. The assessment facilitates the development of an individualized care plan in consultation with an interdisciplinary team. The University of California, San Francisco adapted GRACE to its Care Support Service program for high-risk adult primary care patients. The adapted program led to improved self-rated health and reduced hospital and emergency department use, thereby helping the AMC meet the goals of California’s Medicaid Delivery System Reform Incentive Payment program.10
Employing trained care managers to facilitate coordination among care team members
Nurse care managers are embedded in primary care practices affiliated with Massachusetts General Hospital (MGH) to assess high-risk Medicare beneficiaries’ needs, develop care plans, educate patients, and coordinate care in conjunction with patients’ physicians and care teams. Using this approach, MGH was one of only two participating sites to save money under Medicare’s Care Management for High-Cost Beneficiaries demonstration. Partners Health Care, of which MGH is a part, has implemented this program system-wide as a key mechanism of its Medicare ACO. The program has reduced hospitalizations and Medicare spending by 6%.11
Implementing supportive health information technology
The OneCare Vermont ACO, led by the University of Vermont Medical Center and the Dartmouth–Hitchcock health care system, worked with a vendor to configure a software platform to meet the needs of care coordinators in the community. As a supplement to patients’ electronic medical records, the software identifies the health and social service staff working with particular patients; creates notifications and prompts about hospital admissions, discharges, and other events; and enables care coordinators to create task lists, track activities, and facilitate collaboration. This approach may help to reduce service utilization under Vermont’s all-payer model.12
Promoting patient and caregiver engagement
MedStar Washington Hospital Center’s medical house calls program emphasizes the importance of building trusting relationships among an interdisciplinary care team and patients and their families, as such relationships allow clinicians to have frank discussions about the care that patients wish to receive through the program and at the end of life. The program also provides skills training and support to caregivers, so that they can respond appropriately when their family member has difficulty breathing or is in pain, which lessens reliance on hospitals and emergency departments. The MedStar House Call program earned approximately $1.6 million in shared savings in the first two years of Medicare’s Independence at Home demonstration.13
Partnering with social services to address nonclinical needs
Penn Medicine’s In-Home Primary Care program serves many patients through the Elder Partnership for All-Inclusive Care (Elder-PAC), which enables a home-based primary care team, a nurse from Penn Medicine’s home health agency, and social worker case managers from the local Area Agency on Aging (AAA) to address patients’ needs holistically. The AAA arranges services such as home health aides, day care, housing modifications, transportation, and Meals on Wheels. A study of the Elder-PAC found that it reduced Medicare costs by 50% and reduced nursing home use fourfold.13
Challenges and Opportunities
Volume-based payment models remain a barrier to the wider adoption of the key features of evidence-based models.14 As more AMCs embrace value-based payment, they may have greater flexibility to find ways to integrate services to address the medical and nonmedical needs of clinically complex patients with functional limitations, behavioral health issues, and/or material hardships (e.g., being unable to pay for housing, utilities, or nutritious food), and thereby reduce avoidable health care utilization.
To support the work of AMCs and the further adoption of proven practices, six foundations (the Commonwealth Fund, the John A. Hartford Foundation, the Milbank Memorial Fund, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, and the SCAN Foundation) have formed a collaborative focused on high-need, high-cost patients.15 One of the key initiatives of this collaborative has been to work closely with the Institute for Healthcare Improvement to launch the Better Care Playbook (www.bettercareplaybook.org),16 an online, curated resource designed to assist health system leaders and payers with practical guidance on why and how to improve care for high-need, high-cost patients.
Additionally, AMCs have a critical role to play in influencing the nation’s next generation of medical professionals, who will face increasing pressures to address patients’ nonmedical, as well as medical, needs. To do this, AMCs can provide trainees with strategies to help them identify and find resources to address the social determinants of health; work in team-based environments; and effectively communicate to better serve high-need, high-cost patients. There are several innovations in this space, including the following:
- Interprofessional Student Hotspotting Learning Collaborative: The AAMC, the Camden Coalition of Healthcare Providers, Primary Care Progress, and the Council on Social Work Education have developed a six-month graduate training program for interdisciplinary teams of students from schools around the country to apply a patient-centered approach to working with individuals with complex medical and social needs.17
- Kaiser Permanente School of Medicine: This new institution will draw on lessons from a high-performing health system to help students gain proficiency in identifying and addressing their patients’ medical and nonmedical needs and working on a team while leveraging real-time evidence to inform clinical decisions.18
- Accelerating Change in Medical Education Consortium: With funding from the American Medical Association, 32 U.S. medical schools are investigating how to better prepare medical students to succeed in evolving health care systems. Participants are identifying new roles for medical students, including patient navigators, health coaches, care transitions facilitators, and patient safety analysts, which could enhance their education and improve patient care.19
AMCs have many opportunities to create high-performing health systems, establish operational evidence for how to transform delivery systems, and train the next generation of providers to better address the care of high-need, high-cost individuals. By developing a deeper understanding of this diverse population and working to identify and implement programs that offer them higher-quality care at a lower cost, AMCs can greatly accelerate the path to improving care for the country’s sickest and most expensive patients.
The authors thank Meredith Brown, Martha Hostetter, and Sarah Klein for assistance with manuscript preparation.
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