Proactively Identifying the High-Cost Population

Report
Key Questions Answered
  • How can I segment patients into subgroups to better target care management programs?
  • What tools and resources exist to help identify patients who will likely require high-cost care?
Key Themes and Takeaways

This resource reviews strategies to identify patients who are likely to require high-cost care.

  • The high-cost population is very heterogeneous, and segmentation strategies can inform population subgroups and match appropriate care management strategies accordingly.
  • This population can be segmented into three subgroups: patients with advanced illness, patients with persistent high spending, and patients with episodic high spending. The first two segments are good candidates for care management; however, it is difficult to predict the needs of the third.
  • Common signs of patients with advanced illness include heart failure, cancer, coronary disease, increasingly frequent hospitalizations, and advanced age.
  • Most patients with persistent high spending have chronic illnesses, and many have functional limitations as well as serious mental health and substance use diagnoses.
  • There are two basic ways to identify enrollees for care management: using quantitative data (e.g., claims data) and using qualitative data (e.g., physician referral, patient-reported data). Evidence suggests that a hybrid approach is the most reliable.
Population Addressed
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Expert Opinion
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