National Academy of Medicine

Tailoring Complex-Care Management, Coordination, and Integration for High-Need, High-Cost Patients: A Vital Direction for Health and Health Care

By David Blumenthal, Gerard Anderson, Sheila Burke, Terry Fulmer, Ashish K. Jha, and Peter Long
September 19, 2016 | Discussion Paper
About the Vital Directions for Health and Health Care Series

Vital DirectionsThis publication is part of the National Academy of Medicine’s Vital Directions for Health and Health Care Initiative, which commissioned expert papers on 19 priority focus areas for U.S. health policy by more than 100 leading researchers, scientists, and policy makers from across the United States. The views presented in this publication and others in the series are those of the authors and do not represent formal consensus positions of the NAM, the National Academies of Sciences, Engineering, and Medicine, or the authors’ organizations.
Learn more: nam.edu/VitalDirections

The increasingly complex health-care needs of the U.S. population require a new vision and a new paradigm for the organization, financing, and delivery of healthcare services. Some 5% of adults (12 million people) have three or more chronic conditions and a functional limitation that makes it hard for them to perform basic daily tasks, such as feeding themselves or talking on the phone. This group, “high-need, highcost” (HNHC) people, makes up our nation’s sickest and most complex patient population. HNHC adults are a heterogeneous population that consists of adults who are under 65 years old and disabled, those who have advanced illnesses, the frail elderly, and people who have multiple chronic conditions.

Those complex patients account for about half the nation’s health-care spending. HNHC patients are often people who, despite receiving substantial health-care services, have critical health needs that are unmet. That population will often receive ineffective care, such as unnecessary hospitalizations. By giving high priority to the care of HNHC patients, we can target our resources where they are likely to yield the greatest value—better outcomes at lower cost.

We have an unprecedented opportunity to increase value of health care by rethinking our approaches to serving HNHC patients. The Patient Protection and Affordable Care Act (ACA) offers an array of incentives and tools for pilot-testing and refining alternative delivery and payment models, and many states and private payers have been experimenting with new approaches. Health systems have responded by developing new approaches to health-care delivery and greater public-health outreach. The shift toward valuebased, population-oriented care encourages the multiple providers (in and outside the health-care system) involved in a patient’s care to collaborate to provide appropriate, high-quality care and achieve better patient outcomes. Now we need to disseminate information about successful programs, modify payment and financing systems, create a health-care system that is conducive to the spread and scale of promising innovations, and eliminate remaining barriers that have impeded the adoption of effective approaches to caring for the nation’s most clinically and socially disadvantaged patients. Read more >>

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Note

Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.