Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health

By National Academy of Medicine

Providing care for individuals with significant medical needs disproportionately drives the cost of medical care in the United States. In fact, 5 percent of patients in the U.S. account for nearly half of all health care spending. This population of high-need patients includes a diverse group of people with multiple chronic diseases and varying

• Language: English
• Publisher: National Academy of Medicine
• Release date: Feb 14, 2018
• ISBN: 9781947103078

Book preview

THE LEARNING HEALTH SYSTEM SERIES

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

WASHINGTON, DC

NAM.EDU

NATIONAL ACADEMY OF MEDICINE • 500 FIFTH STREET, NW • WASHINGTON, DC 20001

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.

"Knowing is not enough; we must apply.

Willing is not enough; we must do."

—GOETHE

LEADERSHIP

INNOVATION

IMPACT

for a healthier future

ABOUT THE NATIONAL ACADEMY OF MEDICINE

The National Academy of Medicine is one of three academies constituting the National Academies of Sciences, Engineering, and Medicine (the National Academies). The National Academies provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

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The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on issues of health, medical care, and biomedical science and technology. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

Learn more about the National Academy of Medicine at NAM.edu.

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

PETER V. LONG (Chair), President and Chief Executive Officer, Blue Shield of California Foundation

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

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

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

KATHERINE HAYES, Director, Health Policy, Bipartisan Policy Center

FREDERICK ISASI, Executive Director, Families USA; former Health Division Director, National Governors Association

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

DAVID MEYERS, Chief Medical Officer, Agency for Healthcare Research and Quality

ARNOLD S. MILSTEIN, Professor of Medicine, Director, Clinical Excellence Research Center, Center for Advanced Study in the Behavioral Sciences; Stanford University

DIANE STEWART, Senior Director, Pacific Business Group on Health

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

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:

KATHERINE LEWIS APTON, Program Officer, National Academy of Medicine (until January 2017)

MARIA LUND DAHLBERG, Associate Program Officer, National Academies of Sciences, Engineering, and Medicine (until April 2017)

ELIZABETH MALPHRUS, Associate Program Officer, National Academy of Medicine (until June 2015)

DANIELLE WHICHER, Senior Program Officer, National Academy of Medicine

MINA BAKHTIAR, Senior Program Assistant, National Academy of Medicine (until May 2016)

GWEN HUGHES, Senior Program Assistant, National Academy of Medicine

CARRIE WOLF, Senior Program Assistant, National Academy of Medicine (until March 2016)

BROOKE KEANE, Intern, National Academy of Medicine (until August 2017)

DANIEL BEARSS, Senior Librarian, National Academies of Sciences, Engineering, and Medicine

LAURA DESTEFANO, Director of Communications, National Academy of Medicine

KYRA E. CAPPELUCCI, Communications Specialist, National Academy of Medicine

MOLLY DOYLE, Communications Specialist, National Academy of Medicine

Consultant

JOE ALPER, Science Writer and Rapporteur

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:

BRUCE CHERNOF, The SCAN Foundation

BRUCE HANSON, First Lutheran Church

JULIAN HARRIS, Cigna

GAIL WILENSKY, Project HOPE

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.

The National Academy of Medicine (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 existing system constraints and complexities such as the integration of medical and social approaches and the financing of care models.

I want to recognize the Peterson Center on Healthcare, who funded these activities at the NAM in order to advance our knowledge and actions around this critical issue. The Center also supported associated research projects at the Harvard T. H. Chan School of Public Health and the Bipartisan Policy Center to provide quantitative and policy analysis used to inform these workshops. Those teams provided invaluable input and shared important perspectives throughout the process, as did Melinda Abrams from The Commonwealth Fund.

Thanks also to the hundreds of individuals who participated in the three public workshops. In particular, I want to recognize the patients and caregivers who shared their personal stories at the beginning of each workshop. Their stories provided a powerful reminder why this effort is so important and focused our attention on improving outcomes from their perspectives.

Thank you to the planning group, who remained committed, curious, and engaged throughout the process. The process produced a publication that is both comprehensive in its scope and focused on practical policy solutions. Beyond planning the three workshops, two subgroups addressed specific issues that were raised as gaps in our knowledge. The taxonomy and policy workgroups greatly enhanced the utility of this publication.

Finally, I would like to acknowledge the leadership demonstrated by the dedicated staff at the NAM (Elizabeth, Katie, Maria, Danielle, Gwen, Emma, Michelle, Marianne, Michael, Daniel Bearss of the National Academies of Science, Engineering, and Medicine Research Center, and Joe Alper) who shepherded this project from its inception through the release of this publication. They organized the three public workshops, supported the working groups, and assisted in the drafting of this publication.

As our nation once again debates health care financing approaches that could fundamentally alter people’s access to health insurance coverage and medical care, it is critical to focus attention on those individuals who are the heaviest users of health care and commit to improving their outcomes while reducing spending. There are currently major policy barriers to broad implementation of what we already know does work. Future policies and funding proposals that either ignore what we know works or inhibit us from implementing effective care models will be detrimental to the health of these vulnerable populations. If our goal is to improve the health of our most vulnerable neighbors, we must take effective actions now.

—Peter V. Long, PhD

Chair, Planning Committee

CONTENTS

Acronyms and Abbreviations

Boxes, Figures, and Tables

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 Sketches

Planning Committee Biographies

Taxonomy Workgroup Biographies

BOXES, FIGURES, AND TABLES

Boxes

Figures

Tables