Unbiased Analysis of Today's Healthcare Issues

Who are the high-cost patients?

Written By: Jason Shafrin - Feb• 29•16

Accountable care organizations are responsible for managing the quality and cost of patients.  However, a small share of patients make up a large share of health care cost.  How can ACOs improve the care and reduce the cost of these patients?

First, ACOs need to understand the needs of high-cost patients.  A perspective by Powers and Chaguturu (2016) examine the complexity of these high-cost patients:

The costliest 1% of Medicare patients had an average of eight co-occurring chronic conditions. Most had cardiovascular risk factors, and more than half had end-stage sequelae of ischemic heart disease, congestive heart failure, or chronic kidney disease…In the Medicaid population, high-cost patients also had several co-occurring chronic conditions (an average of five) but there was a striking prevalence of mental health disorders. A quarter of the patients had been diagnosed with depression, another quarter with anxiety, and almost one fifth with bipolar disorder…Drivers of high costs [for the commercially insured population]…included catastrophic injuries, neurologic events, and need for specialty pharmaceuticals — particularly antineoplastics, but also biologics for multiple sclerosis or rheumatoid arthritis.

How can ACOs reduce the cost of care for these patients?  The authors suggest the following:

[For Medicare patients]…the use of nurse care managers who work with high-risk patients to coordinate care among providers, monitor and track outcomes, and engage patients in disease management has been successful in some cases. We also found that 20% of spending in this group is attributable to post-acute care, which suggests the need for strategies aimed at high-value post-acute and skilled-nursing care….[For Medicaid patients] accountable care strategies for this population to improve access to mental health care and to integrate mental health services into broader care-coordination and disease-management models…high cost commercial patients would…need to focus on ensuringappropriate use of specialtypharmaceuticals in treating chronicdisease.

Because high-cost patients in different populations have different needs, it is imperative for ACOs to tailor their case management programs to the needs of these specific patient groups.

You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

Leave a Reply

Your email address will not be published. Required fields are marked *