Guest Commentary: High-need patients are being under-served, and it needs to change

For the most vulnerable, chronically ill among us—many of whom cope with behavioral health challenges and struggle to secure housing, food or transportation—the journey to receive the care they need can be daunting.

All too often, these high-need patients—who make up about 5% of the population but account for roughly half of all healthcare spending—are let down by the system. They encounter a befuddling lack of coordination among providers, which can be both harmful to their health and unnecessarily costly. And their medical care is almost always completely walled off from the community-based services that also impact their health and quality of life.

Yet, the variation that exists in care delivery and outcomes within this population suggest that there are high-performance models that exist and, if widely used, provide a great opportunity for systemic improvement.

High-performance care is simple to describe, but hard to deliver. It should be accessible, holistic and coordinated care that better integrates medical, behavioral and social services to meet individual patients' needs. It should reward better outcomes and lower costs, rather than the amount of care provided.

While we've made some necessary progress in shifting toward incentives that reward outcomes and not volume, it isn't enough. We also need to understand which models of care work reliably for which high-need patients and develop the know-how for accelerating their adoption nationwide.

Indeed, many bright spots have emerged over the last decade. At the Peterson Center on Healthcare, we've been working closely with experts from the Harvard T.H. Chan School of Public Health, the National Academy of Medicine and the Bipartisan Policy Center to better understand segments within the high-need population, match existing care models to these segments and identify policy constructs that can facilitate their spread. This work presents a meaningful opportunity to spread care that delivers better clinical and functional outcomes, an improved patient experience and inspires more "joy in work" for the people who provide the care—all at lower cost.

Fortunately, many leading organizations, including accountable care organizations and Medicare Advantage plans, are delivering more appropriate, coordinated care. Medicare Advantage plans, with their focus on serving Americans over the age of 65, have a special opportunity to help treat the increasing number of senior citizens with complex health and social needs. As we identify promising care models, these organizations will be well-positioned to test and spread these efforts. For instance, the Boston-based Commonwealth Care Alliance has employed new mobile care teams to visit and care for vulnerable, low-income patients in their homes or in their communities. After the first year, enrolled plan members had 7.5% fewer hospital admissions and 6.4% fewer emergency department visits compared to the previous year.

The need to identify, test and spread promising approaches like the efforts in Boston is informing our new collaboration with four other major health foundations—the Commonwealth Fund, John A. Hartford Foundation, Robert Wood Johnson Foundation and SCAN Foundation. Over the years, our organizations have become deeply invested in solving this challenge. Together, we believe we can identify what is and isn't known about effectively preventing, delaying and treating the incidence of chronic illness. As we do, we are targeting innovative ways to address gaps, reduce duplication and accelerate the adoption of what works.

We recently launched our efforts with the Playbook—created in partnership with the Institute for Healthcare Improvement—which curated case studies and evidence on promising delivery models that could potentially be adopted by provider organizations. Read more about it at bettercareplaybook.org.

This is just the beginning. We all need to be open to sharing new ideas so that together we can realize the vital goal of improving how high-need patients are cared for in this country.