- Patients with functional limitations that keep them from living independently are a major challenge for providers focused on population health management, according to a new Commonwealth Fund data brief, especially because these patients incur significantly more costs than other groups.
Complex patients with significant health problems and difficulties engaging in everyday self-care make up five percent of the population, the report found, and they may cost up to three times as much as the average for other patients.
Reducing these costs is one of the major goals of healthcare reform, but clinical care on its own will not make much of a dent in the spending of patients in need of significant daily aid without a deeper insight into the complicated socioeconomic circumstances driving increased utilization, the study argues.
“We have known for a long time that there are very sick patients facing challenges in daily living and that our health care system has to do a better job of caring for them,” said Melinda Abrams, Vice President for Delivery System Reform at The Commonwealth Fund and a coauthor of the reports.
“This research shows us who they are, what their needs are, and how the system is, or isn’t, working for them right now. This gives us a clearer picture of how to help them get and afford the care they need, so they’re able to live their lives to the fullest extent possible.”
In order to help the healthcare system develop a better understanding of the unique needs of patients who rely on family, caregivers, and providers for help with basic daily tasks in addition to clinical management, the study examined data from the 2009–2011 Medical Expenditure Panel Survey fielded by the Agency for Healthcare Research and Quality (AHRQ).
The survey, which was first conducted in 1996, collects information on patient demographics and socioeconomics, use of medical services, access to care, and other quality and experience metrics, supplemented by data from healthcare providers.
“For high-need adults, average annual per-person spending on health care services and prescription medicines topped $21,000, nearly three times the average for adults with multiple chronic diseases only, and more than four times the average for all US adults,” the Commonwealth Fund explained.
High-need patients, defined as those with functional limitations including trouble bathing or dressing, shopping, and preparing food, typically spend twice as much on out-of-pocket healthcare costs as other adults. At the same time, their average median income is just $25,668, or half of the overall adult population.
Patients with functional limitations also tend to spend significantly more than patients that have multiple chronic diseases, but do not need additional self-care support. Average out-of-pocket costs for chronic disease patients with no additional needs was approximately $1157, whereas high-need patients typically paid $1669 in direct expenses.
Twenty percent of the sickest adult respondents to the survey reported going without care, foregoing prescriptions, or delaying necessary services due to the price tag attached to accessing healthcare.
“We are asking the sickest people to pay the most, when they have the lowest incomes,” said co-author Gerard Anderson, a professor at Johns Hopkins Bloomberg School of Public Health.
The study pointed out that the vast majority of these high-need patients did have insurance, even before the implementation of the Affordable Care Act. Only 4 percent reported being uninsured. More than 80 percent of high-need participants were covered by public insurance – significantly more than the general population or those with chronic diseases that did not require additional aid.
“The sickest patients have the highest medical spending but cannot reliably get the health care they need, even though they have insurance,” said Commonwealth Fund President David Blumenthal, MD. “This is a sign that our health care system is failing its most vulnerable patients. Helping patients with the greatest needs should be among the very highest priorities for efforts to improve our current system.”
High-need patients skew significantly older than the general population, with most over the age of 75. Nearly two-thirds are women, likely due to gender differences in expected lifespan, and just under a quarter had not finished high school. Seventy-five percent identified as non-Hispanic white.
Perhaps unsurprisingly, patients with complex needs tended to end up in the emergency department much more often than other groups, and experienced significantly more hospital admissions. While the overall adult population only visited the ED at a rate of 183 per 1000 patients each year, patients with functional limitations saw an ED rate of 619 per 1000. Hospital admissions were also higher by more than 400 patients per 1000 each year.
Five percent of functionally limited patients experienced at least three inpatient stays per year. They also averaged 9.6 doctor’s visit each year, which is about triple the rate of the overall population and 50 percent more than non-limited chronic disease patients.
They also used an average of 26 paid home healthcare days, with the curve skewed heavily towards the 12 percent that utilized 60 days or more. Highest usage of home health services came from patients who had the lowest incomes, the least education, the most advanced years, and dual eligibility under Medicare and Medicaid.
In contrast, patients who reported higher incomes and more education were more likely to visit their primary care providers.
The unique profile of high-needs adults may put pressure on providers to develop population health management programs that address those with the most complex clinical and socioeconomic situations.
Using risk stratification tools and patient assessments to distinguish between patient populations with multiple chronic diseases and those who need additional services to cope with limited functionalities should be the first step.
Providers who serve higher proportions of these patients may also wish to explore partnerships with community health services, such as meal delivery organizations, home delivery pharmacies, and senior citizen activity centers, to ensure that patients are receiving basic services in a convenient and cost-conscious manner.
They should also investigate a team-based approach to caring for patients with high needs by creating care plans that integrate family members, caregivers, and other healthcare professional to ensure that care is appropriately coordinated and that patients have support with medical decision-making, advanced directive planning, and daily tasks.
By addressing population health management for high-need patients in a holistic manner, healthcare providers may be able to reduce unnecessary spending, steer patients to lower-cost service options, and ensure that vulnerable members of the community are receiving the highest possible quality care.