A Recent Study Confirms It: High Volume Contributes to Better Care for High-Needs Patients | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

A Recent Study Confirms It: High Volume Contributes to Better Care for High-Needs Patients

May 10, 2017
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Medical researchers confirm a link between volume of care for high-needs patients and financial and clinical outcomes

A study published in the March issue of Health Affairs confirms what many have suspected all along: medical practices that care for large numbers of high-needs patients—particularly larger-sized medical practices that do so—realize better patient outcomes. Those familiar with Lean management principles would say that of course this would be true. But having this documented and presented in Health Affairs is still extremely helpful.

The article, entitled “Outcomes For High-Needs Patients: Practices With a Higher Proportion of These Patients Have an Edge,” was written by a team of researchers—Dori A. Cross, Genna R. Cohen, Christy Harris Lemak, and Julia Adler-Milstein. The researchers, from the University of Michigan, the University of Alabama-Birmingham, and Mathematica Policy Research, write this: “High-value primary care for high-needs patients—those with multiple physical, mental, or behavioral health conditions—is critical to improving health system performance. However,” they note, “little is known about what types of physician practices perform best for high-needs patients. We examined two scale-related characteristics that could predict how well physician practices delivered care to this population: the proportion of patients in the practice that were high-needs and practice size (number of physicians). Using four years of data on commercially insured, high-needs patients in Michigan primary care practices,” they write, “we found lower spending and utilization among practices with a higher proportion of high needs patients (more than 10 percent of the practice’s panel) compared to practices with smaller proportions. Small practices (those with one or two physicians) had lower overall spending,” they note, “but not less utilization, compared to large practices.”

As the article’s authors note, “It can be challenging for physician practices to manage the needs of healthy and complex patients in parallel, because high-needs patients require more time and resources to treat than healthy patients, and rely more heavily on care management and social services that might be hard to integrate into routine care.”

In terms of the practices studied, the most common chronic conditions and other diseases involved were type 2 diabetes, chronic obstructive pulmonary disorder (COPD), liver disease, asthma, and cancer. In terms of the practices, 63 percent of practices had a minimal proportion of high-needs patients; 34 percent had a moderate proportion; and about 3 percent had a substantial proportion. Meanwhile, 71 percent of the practices studied were small.

As for outcomes, when practices with a minimal proportion of high-needs patients (less than 2 percent), patients in practices with moderate (2-10 percent) and substantial (greater than 10 percent) proportions, had lower spending across all measures. Total medical-surgical spending was nearly 12 percent lower for patients in moderate practices, and more than 40 percent lower for patients in substantial practices. Patients in moderate and substantial practices also had lower odds of incurring any inpatient spending, and, for practices with substantial high-needs patients, lower average total inpatient spending, as well as lower odds of incurring any ED spending.

These numbers are significant. Essentially, these medical researchers found, medical practices that have substantial percentages of high-needs patients—patients primarily with (often-multiple) chronic illnesses, as well as diseases like cancer that require intensive interventions—are seeing 40-percent lower total medical-surgical spending. And in this context, “substantial” practices are those with more than 10 percent of their patients being high-needs patients.

Now, it’s also true that smaller practices with a volume of high-needs patients saw 7 percent lower total medical-surgical spending. But the different between 7 and 40 percent is, of course, quite significant. And, despite the fact that “Patients in practice with a substantial proportion of high-needs patients had an average quality composite score nearly 5 percentage points worse than that of patients in minimal practices,” anyone who’s worked in an outpatient clinic setting can clearly see the benefit of more extensive, intensive delivery of care for high-needs patients.

There are some nuances here. For example, the authors write, “Our second set of findings regarding practice size revealed that small practices had lower spending, but not lower utilization, compared to large practices. The fact that spending and utilization were not both significantly lower might be explained if patients in small practices experienced a similar number of encounters, but with lower length-of-stay or intensity of needed services”—in other words, these providers “did a better job of maintain these patients’ health status such that they avoided serious declines that resulted in higher-intensity utilization.” The authors speculate that the potentially closer physician-patient relationships in smaller practices might be at play there.

Meanwhile, as the authors note, “Our findings were not uniformly positive in favor of practices with  a higher proportion of high-needs patients and small practices, as both performed worse on the composite quality measure. It may be,” they speculate, “that for high-needs patients, adherence to evidence-based guidelines does not feel as pressing as keeping patients out of the ED and hospital. This is supported by our finding that the medication management subcomposite, an important domain of quality for high-needs patients, did not reflect worse performance.”

Still, there is a lot to ponder here, and as the authors state in the conclusion to the article, “Our findings should prompt policymakers to further vet the assumption that practice consolidation will result in better for patients who are most in need. Once the mechanisms underlying our findings are better understood,” they add, “policy makers can consider experimenting with models that feature practices with a higher proportion of high-needs patients and perhaps strengthen efforts to support small practices to help achieve high-value care for this population.”

What’s clear to me is that healthcare IT and data analytics will play a very important role in this, as will data governance and IT governance and management. Senior clinician and executive leaders in medical groups, and to the extent that those medical groups have IT professionals in their trenches, IT professionals, already will be needing to ramp up their outcomes measurement, data analytics, and quality reporting capabilities to participate in either MIPS (the Merit-Based Incentive Payment System), or in advanced payment models (APMs) under MACRA (the Medicare Access and CHIP Reauthorization Act of 2015). Why not take the opportunity to figure out where they’re doing particularly well with patients with chronic and other diseases, and in particular, why not look at patient volume, as a factor in this?

I believe that, as the leaders of medical groups begin to assess and weigh these issues, they will benefit tremendously from coming to understand where their gaps are, and also where their particular strengths are. And they can also figure out how to optimize both their clinical and their financial outcomes in areas key to their success with patients—and with payers. And, as usual, healthcare IT leaders can prove themselves heroes here—by helping to uncover what needs to be uncovered, and help their organizations move towards better outcomes of all kinds.

And in the meantime, studies like this one will continue to shed light on where the U.S. healthcare system as a whole needs to go to improve outpatient care in the clinic setting—an exceptionally important set of concerns going forward.





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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”


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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.



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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

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NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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