It is well documented that 5% of the population account for 50% of healthcare spend.1 Provider organizations, such as ACOs, often focus expensive complex care management resources on this patient population segment, often referred to as “high-risk” patients. While conventional wisdom supports the approach, a subcategory of “rising risk” patients may represent an even greater opportunity to drive quality and lower the overall cost of care.
Understanding the Difference
Complex care management involves multi-disciplinary, licensed staff who coordinate closely with primary care teams to meet the needs of a practice’s high-risk patients. Selected cohorts may include patients with multiple co-morbidities, selected transitions of care and/or Emergency Department (ED) over-utilization. A complex care management program might also include high-risk patients within certain medication-focused or demographic categories. Such patients are often “high touch,” requiring both face-to-face and telephonic support, and have had numerous acute care episodes and/or high utilization of multiple resources. Keep in mind that while preventing additional acute episodes is important to prevent additional spend, the cost incurred has already occurred and cannot be altered.
Once identified, care coordinators proactively ensure that these patients receive the right care, at the right place, at the right time using predictive analytics, customized care plans, point-of-care decision-support tools embedded within an EHR, and access to a high quality/high value provider network. While larger provider organizations may be able to support embedded care coordinators, most groups find that a centralized care coordination team serving multiple providers is far more cost-efficient.
“Rising risk” patients have poly-chronic conditions but may not have had an acute care episode. They are also characterized by the severity of their diagnoses, with clinical indicators of increasing disease burden. Health Risk Assessment (HRA) tools help reveal multiple risks, including key health metrics, behavior and family history. The ability to isolate this cohort could mean the difference between a financial win or loss within your ACO or payer-sponsored value-based program, as the higher cost of care associated with high-risk patients has not yet occurred.
Care coordinators often review existing data and schedule overdue tests or conduct medication reconciliation, for example, as part of a preemptive strike to avoid acute care episodes.
Quality Doesn’t Equal Lower Cost of Care
In 2013, 74% of Medicare’s MSSP 220 ACOs did not earn shared savings. In addition, 47% did not lower the cost of care, even though participants surpassed FFS providers’ quality in 17 of 22 PQRS/GPRO measures.2 Though there are multiple factors, arguably one of the most important was the lack of a “cost of care strategy.”
While approaches may be different based on a particular provider organization or the value-based program targets, a step toward lower cost of care begins with pre-empting high utilization, particularly among patients who have yet to incur high cost care. By identifying them, proactively managing care and supporting access to high quality/high value providers within the ACO, your organization will be one step closer to achieving the Triple Aim and potentially earning shared savings.
Download our whitepaper, Coordinated Care: Key to Succesful Outcomes to read about care coordination, the need for well coordinated care, and the benefits of centralized care coordination.
1."1 Percent of People Account for 23 Percent of Medical Spending." Health Policy Blog RSS. National Center for Policy Analysis, 5 Nov. 2014. Web. 14 Mar. 2016.
2. "Medicare ACOs Continue to Succeed in Improving Care, Lowering Cost Growth." 2014-11-10. Centers for Medicare & Medicaid Services, 10 Nov. 2014. Web.