High-Need, High-Cost Care

Fellowship Year 2017-2018

Background

In the U.S., the distribution of health care spending is strongly skewed, with the top 5% of healthcare spenders accounting for 50.4% of the total $3.2 trillion in health care spending in 2014. This population is often termed high-need, high-cost (HNHC) due to the high burden of multiple chronic medical and behavioral health (BH) conditions, functional limitations, and social risk factors.2 Patients with complex social and medical needs experience substantial difficulties when trying to navigate our highly fragmented healthcare system. As a consequence, social determinants of health as well as many medical and emotional needs remain unaddressed and thus keep contributing to poor health and increased healthcare utilization. 

Safely reducing per capita care spending in High-Need, High-Cost patients CERC's HNHC care redesign team identified three addressable suboptimal points in current care delivery methods aimed at HNHC patients, summarized in the table below. The HNHC care redesign team addressed these failure points via a new care model that encompasses three core elements:

(1) Promote alternate care settings that provide safe and lower cost alternatives to EDs and hospital admissions. This strategy includes (a) empowering paramedics to assess and treat patients at home (Community Paramedicine) and (b) using alternative care sites for acute intoxications with no other medical needs or injuries (Sobering Centers).

(2) Integrate behavioral health (BH) and primary care. The best evidence of clinical efficacy and cost savings points to the Collaborative Care Model of BH integration. In this model, the PCP oversees the BH care and provides prescriptions. A BH care manager provides systematic follow up of patients, communication among providers, and psychotherapy interventions. A psychiatrist provides tele- or in-person consultation and supervision to the PCP and the care manager.

(3) Identify and invest in health-related social issues that have a sustainable return on investment for healthcare alone. In particular, CERC's care redesign team advocates for (a) providing targeted non-emergency medical transportation (NEMT), and (b) housing the high-cost homeless.

Estimated savings

A conservative estimate of national savings from the full implementation of the CERC model is 1.5+ billion dollars in direct healthcare spending per year, or 2% of annual spending for the HNHC population. Additional savings are likely if the model is extended to wider populations, such as primary care populations, or the adult Medicaid population.

Authors

Chuan-Mei Lee, MA, MD; Danielle Rochlin, MD; Claudia Scheuter, MD; Arnold Milstein, MD, MPH, 2018