Highmark Health

Jo Clark

Managing the care of specific populations well deserves the focus it’s receiving in the health care community. We now have available to us more advanced strategies, tools, information and actionable insights than ever to apply to establishing new or updated best practices for the care and treatment of all kinds of patient populations—young and older, sick and well, and across many comorbidities.

"To be successful, programs that are treating this fragile population need to be laser-focused on their unique needs and combine four key pillars"

A population extra-deserving of our focus is patients who are living with complex health conditions. They present an urgent opportunity to improve health outcomes and lower medical costs.

The landmark National Institute for Health Care Management Foundation studies showed that nearly half of all health care spending is associated with just 5 percent of the population. Our own data bears this statistic out. These are typically older patients with one or more chronic conditions or physical limitations. All told, this small population represents billions of dollars in health care spending in the U.S., and presents one of the best opportunities for our generation to reduce the cost of health care spending in the U.S. and improve the health, quality of life, and overall experience of these patients.

Patients with complex conditions are at-risk for increased hospitalization, health complications and poor health outcomes. Increased hospitalization occurs in the form of more emergency room visits, more inpatient stays and more readmissions than among more typical patient populations.

To be successful, programs that are treating this fragile population need to be laser-focused on their unique needs and combine four key pillars. First, the program needs to be integrated, coordinated and personalized. A multidisciplinary team—clinical, social and behavioral—needs to literally surround the patient with well-coordinated touchpoints to bring about better care, improved outcomes, and change.

Second, the program needs to be focused on prevention, patient engagement and satisfaction, and health outcomes. Patients need to be enlisted as true partners in the journey towards better health. That takes behavioral experts who understand how to motivate people.

And that leads to the third pillar—the program needs to help patients sustain behavioral changes that can improve the quality of life and health, long-term. It’s as much about a patient’s ability to self-help, self-care and self-love as it is about the compassionate care we can provide.

Finally, the program needs to be measured across multiple criteria including cost efficiency as well as utilization, health outcomes, and patient experience.

A team-based, high-touch approach based on these pillars is easy to outline and a mountain to climb. It requires a willing population to work with, a commitment to implement and continue to iterate until a best practice model can be hardened, and a multi-disciplinary team that believes they can change the course of a patient’s health and ultimately the outcome of an entire population. Plus the investment is substantial and well beyond more familiar models of health care and care management. But the return on the investment in dollars and health goes potentially well beyond the traditional model of care as well—especially given that the cohort of 5 percent of the population driving more than 50 percent of total health care spend lies at the base of the mountain now.