We’re Getting to Know What the High-Needs Patient Population Looks Like—and Seeing Clear Gaps | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

We’re Getting to Know What the High-Needs Patient Population Looks Like—and Seeing Clear Gaps

May 25, 2017
| Reprints
Some recent research and analyses shed light on what we need to know about high-need patients going forward into care management

There’s so much going on right now around population health management and care management, it really is worthwhile to pause for a moment and think about a key question: what do we know about patients with high and complex needs—the patients who are going to be the clear focus of many of the efforts going forward in the U.S. healthcare system? Let’s take a step back and consider.

To begin, the announcement a week ago that the federal Centers for Medicare and Medicaid Services (CMS) was expanding the map of regions open to participation in its Comprehensive Primary Care Plus program, or CPCP+, was yet another signal that federal officials are looking to expand the ways in which the federal government can help providers provide higher-quality, more efficient patient care in a primary care setting.

As I wrote in a blog on the topic earlier this week, the CPC+ program’s core payment elements—including paying a care management fee to primary care practices to account for the intensity of care management services required for the specific population of individual practices; the prospective payment of performance-based incentive payments; and a shift in how fee-for-service payments are made, to account for participation in the CPC+ Program—are elements in CPC+ that build on the original Comprehensive Primary Care Program, and  that are intended to incent improved care management and patient outcomes.

And, in that blog, I wrote this: “What CPC program participants have been learning, and what CPC+ program participants will be learning going forward, could help reshape care delivery at the primary care level—the potential here is enormous. And healthcare IT leaders will need to be broadly and deeply involved at all levels, working as a team with clinician leaders and frontline clinicians to get it done. And, given the five-year framework of CPC+, you can bet we’ll be hearing about developments in this critical initiative going forward. Meanwhile, there’s not a moment to waste for the healthcare IT leaders and professionals working with the leaders of primary care practices involved in CPC+, in order to make rapid advances to show that it can be done. I’m excited by the prospects, and will be watching the forward evolution of this program very closely, in the coming months and years.”

I also noted in a blog earlier this month the results of a recent KPMG study that found that both provider and payer organizations are gaining ground in effectively using population health IT infrastructures and platforms to care-manage patients. As I noted in the May 9 blog, “According to that survey, provider and health plan leaders are making progress in key areas. As stated in the consulting firm’s Jan. 23 press release, ‘In the survey, 44 percent of respondents at payer and provider organizations found that they have a population health platform in place that is being ‘utilized efficiently and effectively.’ Another 24 percent are in the process of implementing a population health program within the next three years. Only 10 percent said they have no plans to implement a population health platform and another 21 percent of respondents said their organization doesn’t require a population health platform.’”

In that blog, I further noted that KPMG’s researchers had found that “The biggest individual barrier to implementing a population health program is aggregating and standardizing information from multiple sources, 30 percent of respondents said. Stakeholder adoption (10 percent) and integrating with clinical work flows (10 percent) were cited as additional barriers. Another 34 percent cited ‘all of the above,’ which includes those barriers, as well as enabling patient engagement, funding investments, and selecting appropriate vendors as additional challenges.”

I’ve recently also written a blog noting what’s been learned at one innovative organization, Massachusetts General Hospital in Boston, whose leaders had participated in the Medicare Care Management for High Cost Beneficiaries Demonstration and had developed an intensive care management program, in what turned out to be a test run for what later became the Pioneer ACO Program. Writing in the May issue of Health Affairs, a large team of researchers led by John Hsu found, in examining Mass General’s program, that “The care management program (the ACO’s primary intervention) targeted beneficiaries with elevated but modifiable risks for future spending. ACO participation had a modest effect on spending, in line with previous estimates. Participation in the care management program was associated with substantial reductions in rates for hospitalizations and both all and nonemergency ED visits, as well as Medicare spending, when compared to preparticipation levels and to rates and spending for a concurrent sample of beneficiaries who were eligible for but had not yet started the program. Rates of ED visits and hospitalizations were reduced by 6 percent and 8 percent, respectively, and Medicare spending was reduced by 6 percent.”

Looking at high-need patients—and the gaps in their care management

All of these learnings and so many more will be needed going forward to achieve outcomes breakthroughs among patients with high and complex needs, as an article published on the website of the Commonwealth Fund in December makes clear. In the article, entitled “As New Survey Describes Scope of Problem, Five National Health Care Foundations Identify Promising Approaches for Treating Patients with Complex Needs,” published on the organization’s website, Commonwealth Fund leaders note that “A new nationwide survey of patients with complex medical needs shows that the health care system is failing them, with these individuals having far more unmet behavioral health and social service challenges than other adults. While nearly all of the high-need patients surveyed have consistent access to health care (95 percent),” the report notes, “they nevertheless struggle to get the coordinated medical, behavioral, and social services they need to stay well and avoid costly hospital visits. Specifically, they had limited access to: care coordinators, assistance in managing functional limitations, emotional counseling, and transportation services.”

In this context, Commonwealth Fund researchers defined high-needs patients as “patients with clinically complex conditions, cognitive or physical limitations, or behavioral health problems,” including “people with two or more major chronic conditions like diabetes or heart failure,” some of them with “unmet social needs that may exacerbate their medical conditions.” In any given year, Commonwealth Fund researchers note, “Ten percent of patients account for 65 percent of the nation’s health care expenditures.”

Importantly, the article notes, “The Commonwealth Fund survey of 3,009 adults (1,805 of whom are high-need) is being released as five national health care foundations—The John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, The SCAN Foundation, and The Commonwealth Fund—launch a new online resource to help health system leaders and insurers improve care for patients with complex medical and social needs.”

In that regard, the Commonwealth Fund’s survey confirms some of the things already known about the high-needs population, but that deserved being affirmed by the survey. Among them:

Ø  Compared with the general population, the high-need population is older, has lower levels of education and income, and includes more women and African-Americans.

Ø  High-need patients use more health care services than other adults, as has been reported in previous analyses.

Ø  Nearly half (48 percent) of high-need respondents were hospitalized overnight in the past two years.

Ø  A similar percentage (47 percent) went to the emergency department multiple times in the past two years.

Ø  Approximately one of five (19 percent) used the emergency department for a condition that could have been treated in a doctor’s office or a clinic.

Ø  Adults with high medical needs often have unmet emotional and social needs. The survey results indicate that this group is more likely than the general population to report experiencing emotional distress that was difficult to cope with on their own in the past two years.

Ø  Indeed, 37 percent of high-need respondents reported often feeling socially isolated, including lacking companionship, feeling left out, or feeling lonely or isolated from others, compared with 15 percent of other adults.

Ø  Almost two-thirds (62 percent) of high-need respondents report stress or worry about material hardships, such as being unable to pay for housing, utilities, or nutritious meals, compared to only one-third of other adults (32 percent).

Ø  Furthermore, six of 10 (59 percent) high-need adults report being somewhat or very concerned about being a burden to family or friends.

Ø  More than two-fifths (44 percent) of high-need patients reported delaying care in the past year because of an access problem such as lack of transportation to the doctor’s office, limited office hours, or an inability to get an appointment quickly enough.

Ø  Nearly one-quarter (22 percent) of high-need respondents specifically reported a lack of transportation as a reason for delaying care, compared with only 4 percent of other adults.

Ø  Three of 10 (29 percent) of high-need respondents reported delaying care specifically as a result of not being able to get an appointment soon enough with their regular provider.

Interestingly, nearly 95 percent of high-need survey respondents reported having a regular physician or place of care; yet only two-thirds of adults (65 percent of high-need and 68 percent of other adults) report being able to get an answer the same day when they contact their doctor’s office with a medical question, in line with similar analyses.7 In particular, high-need respondents report difficulty being able to get after-hours medical care on weekends, evenings, or holidays. And only one-third (35 percent) of high-need respondents reported it was somewhat or very easy to get medical care after-hours without going to the emergency room, compared with more than half (53 percent) of other adults.

All of these statistics coming out of the Commonwealth Fund survey are confirming a lot of what we already knew about high-need patients—a group that includes both patients with two or more chronic conditions, and also patients with clinically complex conditions, or with both physical and behavioral issues, or with cognitive or physical limitations.

Here’s the thing: what the leaders of patient care organizations, and health plans, who are building infrastructures for population health management and care management, need to do, clearly, is to work along several dimensions at once. There is so much beyond the purely clinical or medical aspects of care management, and the results of this Commonwealth Fund survey, as well as the analyses I’ve mentioned above, speak to the complexity, the challenges—and yes, the opportunities—inherent in developing robust, effective care management programs for patients with high needs.

What’s more, I see IT and analytics as being incredibly important in all this, and at every level of activity. I’ve been involved in many discussions in the past year or two with industry leaders, around this broad subject. Everyone agrees that we need to get far more demographic, socioeconomic, and other data, around covered populations. So very many of the factors that ultimately impact patient outcomes aren’t strictly medical at all. I remember writing an article 20 years ago now, in which I was researching advances in care management on the part of health plans, for their dual eligible members—individuals qualified to receive healthcare coverage under both Medicare and Medicaid. Those individuals are by definition older and poorer; and they often have very complex personal situations. One health plan whose care management leaders I interviewed, had done things like ensuring that case managers went to dual-eligible plan members’ homes in order to see what their home environments were like. In a few cases, the health plan ended up purchasing handrails for their houses. It was really a simple decision to make, the chief medical officer of the health plan told me. When you look at the cost of purchasing the  materials and hammering handrails into the walls of a plan member’s hallway in their home--$100, say—that cost is infinitesimally small when compared to the cost to the health plan of that plan member’s falling in her/his home, breaking his/her hip, and going into a whole different set of care delivery and care management processes. It’s the right thing to do, too, of course.

But the U.S. healthcare system, which has been for its entire history deeply and broadly fragmented, along so many dimensions, is only beginning now to catch up to these realities. And providers are being pushed forward by their taking on risk-based contracts, which are compelling them forward to expand what had been the limits of care delivery and care management.

Frankly, it’s absolutely time—some would even say, past time—that the U.S. healthcare system is moving forward towards more comprehensive approaches to care management and population health management. And for that, we really can thank federal healthcare officials, who have been using various provisions within the Affordable Care Act to compel readmissions reduction, encourage the development of affordable care organizations and bundled-payment contracting, and shepherd forward comprehensive primary care.

The time is now—and healthcare IT leaders’ efforts will be essential, in depth and in breadth, to help create the IT and analytics infrastructures to support all of this work. It will be  bracing time for CIOs, CMIOs, and everyone who works with them—but also a very exciting one. And in the next few years, all of these kinds of initiatives will accelerate forward. But a key element in all of this, not surprisingly, will be getting to know patients with high and complex needs, in greater depth and breadth—that element will prove absolutely essential to every successful effort going forward.





The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



More From Healthcare Informatics


Can Informatics Drive Clinical Quality Improvements Alongside Operational Improvements in Cancer Care?

Thursday, December 13, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more substantial role in improving outcomes and reducing cost of cancer care.

In this webinar, we will review how tumor board solutions, precision medicine frameworks, and oncology pathways are being used within clinical quality programs as well as understanding their role in driving operational improvements and increasing patient retention. We will demonstrate the requirements around both interoperability and the clinical depth needed to ensure adoption and effective capture and use of information to accomplish these goals.

Related Insights For: Population Health


At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
| Reprints
The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


Can Informatics Drive Clinical Quality Improvements Alongside Operational Improvements in Cancer Care?

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more...

Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



See more on Population Health

agario agario---betebet sohbet hattı betebet bahis siteleringsbahis