Proactively Identifying the High-Cost Population

July 2015
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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.
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Population Addressed
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
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?
Level of Evidence
Expert Opinion
What does this mean?