Chokshi DA. A Bipartisan “Moonshot” in Health: Improving Care for High-Need Patients. JAMA Health Forum. Published online July 19, 2017. doi:10.1001/jamahealthforum.2017.0034
Drawing comparisons to a “moonshot” in health care is usually reserved for breakthroughs like curing cancer. Perhaps less hyperbolic, though no less impactful, is the idea of transforming care for high-need patients—people with multiple, and often interconnected, medical, social, and behavioral health needs. Better care for these patients is also a promising approach to reining in health care costs, a bipartisan health policy priority.
About 12 million adult patients have 3 or more chronic conditions as well as functional limitations, such as difficulties with self-care. The size of that patient population also approximately maps to the oft cited 5% of patients who account for half of national health spending. In some ways, focusing on this group is common sense; it derives from the venerable notion of “triage” in medicine. Yet our health care system does not effectively triage the slower-moving emergencies of chronic conditions, including mental illness and addiction. Sadly, the fragmentation that plagues the health care system as a whole is felt most acutely by high-need patients and their caregivers.
However, the movement to address caring for high-need patients is gathering momentum. A new National Academy of Medicine (NAM) special publicationa on effective care for such patients was the product of a partnership between the NAM; the Bipartisan Policy Center; and 2 foundations, the Peterson Center on Healthcare and the Commonwealth Fund. Another 3 foundations joined the Peterson Center and Commonwealth Fund in collaborating on practical approaches to meeting the needs of complex patients. For example, they worked with the Institute for Healthcare Improvement (IHI) in developing a web-based resource, The Playbook—a compendium of information on high-need patients, targeted toward health system leaders, payers, and policy makers.a
There are no silver-bullet interventions for patients with complex needs, but a step forward starts with health systems and payers asking, “Who are our high-need patients, and what are we doing to improve care for them?”
The NAM report offers 14 specific, evidence-based care models that payers can support and systems can implement. Four major common elements undergird the care models: accounting for patient heterogeneity, centering interventions around relationships, enhancing primary care, and supporting caregivers.
First, accounting for individuality and heterogeneity means recognizing the whole-person needs of complex patients. Two patients with similar medical conditions may have very different life experiences, and care models must accommodate that reality to be effective. Programs must respond to how patients choose to seek (or not seek) care and use creative methods to engage patients longitudinally. For example, at the University of Pennsylvania, community health workers with backgrounds similar to those whom they serve work with patients who have visited the emergency room 3 or more times in the prior 6 months.
Second, successful care models build and nurture relationships between patients and care teams. Behavior change, often the crux of any effective intervention, requires trust, which in turn derives from an enduring relationship. The Southcentral Foundation in Alaska has organized a community-based health system around relationship-centered care. The focus on relationships permeates its approach, even in physical layout of its clinics. For instance, whenever possible, a “talking room” is used instead of an examination room to put patients on equal footing with members of the care team.
Third, evidence-based care models are often anchored in primary care, but this requires enhancing the usual clinical services provided in primary care, particularly with resources to address behavioral health and social needs. For example, the IMPACT model brings depression treatment to the primary care setting, and the Program of All-Inclusive Care for the Elderly (PACE), geared toward frail elders (particularly those who are dually-eligible for Medicaid and Medicare) integrates comprehensive clinical care with social services, such as adult day care, meals, and transportation.
Fourth, improving care for high-need patients requires a renewed focus on caregiving. The hard work of attending to patients’ hour-to-hour needs—such as bathing, dressing wounds, and giving medicine—is mostly external to the clinical system, borne by family caregivers, home care workers, and others. Ai-jen Poo, author of The Age of Dignity, writes of this “invisible workforce,” noting that “there are far too few workers who are positioned and prepared to provide care for the growing number of elders and people with disabilities.” Supporting caregivers involves direct assistance, such as Hawaii’s recent legislation to provide employed family caregivers with $70 per day in help from home aides, as well as better incorporating them into the health care system.
Even as these contours of useful strategies emerge, the evidence base for what works for high-need patients at scale must continue to be shored up. A specific methodologic issue in program evaluation is the effect of regression to the mean. The natural tendency for high-utilizing or high-cost patients to become less so over time means that evaluations should include an appropriate control group, and optimally a randomized design. An exemplar is the randomized trial of a care management program for “super utilizers” undertaken by the Camden Coalition for Healthcare Providers. Another fundamental empirical question is the magnitude of overall cost savings that care management can engender. Some scholars have raised important reservations about a strategy oriented around high-cost patients in lieu of a more systematic approach to low-value care.
A bipartisan policy effort of any sort might seem like a “moonshot,” given the current political gridlock. But former Senate majority leaders Tom Daschle and Bill Frist, MD, argue that delivery system reform is inherently bipartisan, given the shared goal of a high-quality, affordable health system. Both Daschle and Frist are part of the Bipartisan Policy Center, which released a report earlier this year suggesting that Medicare should be at the center of policy development for high-need patients, drawing upon a long history of working across the aisle to improve Medicare. The report identifies about 3.65 million high-need Medicare beneficiaries who are not dually eligible for full Medicaid services—and who would benefit from social supports such as meal delivery, nonemergent medical transportation, and care management.
At the state level, there is also an opportunity for policy innovation, particularly in Medicaid. California recently announced a $1.5 billion initiative to integrate medical and social services for high-need Medicaid beneficiaries. The Hawaii caregiver support program shows that the most impactful policies for complex patients may not be what is traditionally considered health policy. In the same vein, some states are providing supportive housing for homeless patients and people with serious mental illness covered by Medicaid.
Integrating medical, behavioral health, and social services; better linking caregivers with health systems; and fostering relationship-centered care would be consequential for millions of high-need patients and might also lead to broader solutions for our delivery system as a whole. The challenges with delivering on this vision are substantial, but worthy of a major collective effort to address them.
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Dave A. Chokshi, MD, MSc Dave A. Chokshi, MD, MSc, is Chief Population Health Officer at New York City Health + Hospitals, clinical associate professor at NYU School of Medicine, and primary care physician at Bellevue Hospital. Previously, Dr Chokshi served as a White House...