Accountable care organizations that engage primary care physicians are more apt to get buy-in on programs that target high-need, high-cost (HNHC) patients, according to a report by The Commonwealth Fund.
The study looked at how new payment and care delivery models, such as ACOs, are meeting the needs of these patients.
Researchers suggested a hybrid model of quantitative and qualitative data that identifies people who can most benefit from care management as the best approach to help HNHC patients.
HNHC patients make up only 5% of the population but account for 50% of healthcare spending. ACOs and other value-based payment models are looking to improve care and quality while reducing costs. That includes bending the cost curve of the highest-cost patients.
CMS has found cost savings in ACOs, such as its Medicare Shared Savings Program.
ACOs use many approaches to segment HNHC patients. "Findings on how mature ACOs are segmenting their HNHC population can improve the future development of more systematic approaches," according to the report.
ACOs use predictive modeling and risk stratification as a way to divide the patient population into risk levels. Population segmentation helps ACOs understand patient needs. This, in turn, influences how the ACO delivers care management and better connects with HNHC patients.
However, The Commonwealth Fund said the approach has led to mixed results. That could be because the ACOs don't drill down further and divide the patients into smaller subgroups.
Few ACOs are doing that work, but the report found that approach has potential. Researchers conducted telephone interviews with 34 leaders from 18 ACOs and 10 national experts in risk stratification and segmentation.
They found that algorithms based only on claims data don't offer adequate clinical, behavioral health or social need information. Also, previous research shows patient health risk assessments or physicians choosing patients for care management aren't effective.
Instead, the report suggested a hybrid model that uses quantitative and qualitative data to segment a population and identify patients for care management is the best approach.
Providers have also increasingly looked at social determinants of health as key factors in health outcomes. People without transportation or stable housing are more apt to suffer from health-related issues than others. Providers and payers have been working on programs to address these issues and collaborating with community groups in offering services to patients in need.