Identifying Patients Who Are More Likely to Use Avoidable Costly Care May Be Key to Controlling Costs

Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. The Commonwealth Fund recently set out to find out who these patients are. By examining demographics and data regarding health care spending and use of services among adults with high needs, they were able to define this group as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks.

Even with Medicare, many high-need, high-cost adults are frequently underinsured and face high cost burdens, particularly those who are older and disabled.2 Providers and payers could consider services such as telemedicine, visiting nurses, and transportation that can help effectively engage and care for mobility-limited patients in a cost-effective manner. Though the focus-group patients were likely more familiar with technology than the average patient given their willingness to engage in video chats, comfort with technology is a quality, or “resiliency factor,” researchers should consider when developing programs to help these patients manage their health. To review our work on this population so far, visit our High-Need, High-Cost Populations page—and look for more research on defining and designing solutions for these patients.

Synopsis

After reviewing medical records for approximately 98,000 adults, researchers found that patients who did not feel competent to manage their own health or navigate the health care system were more likely to develop a chronic disease over a three-year period than “activated” patients with good self-management skills. Low patient-activation levels were also linked to significantly greater likelihood of hospitalization and emergency department (ED) use for “ambulatory care–sensitive” conditions—those that are avoidable if managed properly.

The Issue

The success of population health management depends, in part, on accurately identifying patients at high risk for poor health outcomes as well as preventable and costly health events. Risk-stratification approaches typically focus on clinical markers. This Commonwealth Fund–supported study explored whether considering a patient’s self-management skills and confidence—as predicted by the commercially available Patient Activation Measure (PAM)—might help health care delivery systems pinpoint additional high-risk patients who could benefit from supportive interventions. The Patient Activation Measure assigns patients a score of 0 to 100. Patient can be further grouped into four activation levels, with level 1 representing patients with the most limited self-management skills.