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.