7 things to know about high-need patients

The Commonwealth Fund has released two new issue briefs on high-need patients, aiming to better understand the characteristics of these patients instead focusing on costs alone.

The studies defined high-need patients as people with three or more chronic diseases and some sort of functional limitation in performing daily tasks or being able to care for themselves. As many as 12 million Americans fell into this category, and the studies often compared this group to the estimated 79 million people who have three or more chronic conditions but without functional limitations, along with the overall adult population.

1. Functional limitations means higher costs, lower income. The average high-need adult spent more than $21,000 annually on healthcare services, many times higher than those without functional limitations ($7,500 per year) or the total adult population ($4,800 per year). They also spent more on out-of-pocket expenses ($1,669 per year) while having a median household income of less than half that of those with multiple chronic conditions without functional limitations ($25,668 vs. $52,499). More than 50 percent of the high-need population had income less than 200 percent of the federal poverty level.
2. They tend to be older, female and white. More than half were age 65 or older, and, of that group, most were older than 75. Nearly two-thirds were women (which may be because women tend to live longer than men), and nearly 75 percent of high-need adults were white.
3. They tend to be publicly insured. While the survey predates the major coverage expansions of the Affordable Care Act, more than 80 percent were covered by Medicare, Medicaid or a combination of the two. Only 4 percent were uninsured at the time of the survey.
4. Privately insured have more “unmet medical needs.” Overall, 20 percent of high-need adults reported delaying necessary medical care or prescriptions, higher than the 12 percent in the group without functional limitations and the 13 percent among all adults. Foregoing care was most common among the privately insured, with 32 percent reporting unmet medical needs, followed by 28 percent with Medicaid alone.
5. Not all high-need adults are frequent utilizers. While they are three times as likely to be hospitalized as the other two groups, the study argued they can’t be reached through hospital-based programs alone. Nearly two-thirds (65 percent) of high-need adults had no visits to emergency departments in a year, while 3 percent visited four or more times.
6. They visit the doctor more often. High-need patients visited physicians an average of 9.6 times per year, 50 percent more than those without functional limitations.
7. Frequent visits don’t equal better care or communication. High-need adults were less likely to report having good communications with their providers, with only 40 percent saying their provider 1) spent enough time with them, 2) showed respect, 3) listened carefully and 4) explained things in simple-to-understand terms.

Both reports said high-need adults could prove to be a challenge for value-based care models, as they’re “more likely to continue to incur high healthcare spending than their counterparts who are not functionally limited,” meaning the same solutions to covering other segments of the aging population may not be as effective with this population.

“These findings suggest the health care system is not optimally configured to serve adults with high needs,” the report said. “Our findings reinforce other research that shows that having a functional limitation in combination with multiple chronic diseases imposes a greater burden on patients than multiple chronic diseases alone. This additive burden must be taken into account when designing care systems for high-need patients.”