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Insights on High Risk Patients: More than Traditional Care Management

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The article in Accountable Care News in February 2018 by Dr. Reisman details his ideas on why the savings for high risk complex patients were less than anticipated2. He postulates that the savings are less than expected because the high-risk patients do not benefit from the evidence-based interventions that should keep them as healthy as possible. He maintains that there are additional activities that an ACO could undertake to ensure adherence to treatment pathways that maintain optimal health, such as “ensuring and reinforcing diagnostic and therapeutic strategies that are in line with guideline-directed medical therapy”. There is good evidence that patients receive guideline-based treatment only half the time,3 so the question he poses is: “should we be surprised that the savings we see in value-based care models from care coordination of low-risk patients does not extend to high-risk patients with chronic diseases? In order for care coordination to be successful for high-risk patients, systems that highlight inappropriate care and engage physicians to deliver GDMT [guideline-directed medical therapy] need to be embedded in the health IT platforms of ACOs and other value-based care models.”

However, many ACOs implement specific pathways in their outpatient electronic medical records to help patients receive the guideline-based care that they need. Health systems have created specific clinics for the care of the high-risk patients that deliver the care dictated by guidelines. These pathways and clinics have been implemented as prompts to the prescribing physicians to deliver the highest quality care possible. Although there is always room for improvement, ACOs recognize that pathway driven care for the highest risk patients is an essential component to high quality healthcare.

Dr. Reisman also believes that ACO incentives are targeted at the wrong areas, stating “Looking at only process measures as a way to evaluate quality of care is like evaluating a jet plane by checking tire pressure and fuel levels, and assuming that’s enough data to determine whether or not the plane will crash mid-flight; the reality of aviation is that planes must be monitored all the time, throughout flight, and complex, interconnected pieces of information must be considered.”  Utilizing the idea of patient complexity and the interconnected nature of complex illness, many ACOs have incorporated new ways of exploring how patients experience health conditions. The current medical model asks patients to interface with the medical system at specific locations and times, but this model of care interaction may not result in some high-risk patients achieving their therapeutic goals.

One of the solutions that has been put in place is the use of Community Health Workers (CHWs) to address the needs of patients with chronic illnesses, many of which overlap with social conditions. These CHWs help navigate appointments, translate what physicians have recommended as the course of treatment, and identify and solve for social issues such as lack of support systems that adversely impact health outcomes. CHWs may follow a set of well established guidelines for assessment of patient needs, many of which can be overlooked in the traditional health system, such as the presence of social isolation and how that can contribute to patient lack of adherence to recommended treatments.

As an example, the Value Care Alliance in Connecticut has seen a marked reduction in Emergency Room visits and inpatient admissions for complex patients: 27% reduction in both inpatient admissions per thousand and ED visits per thousand in the high-risk patients seen by the CHWs. Although this is a large reduction, only a small percentage of the overall at-risk patients can be managed by the CHWs due to the intensive nature of their work. These findings reinforce the observations by Chernew et al regarding the impact of managing high-risk patients: a relatively small percentage of the total savings is attributable to management of complex patients.

What needs to be kept in mind is that care management has different definitions for different ACOs and is an intensive and expensive process.  Traditional care management has not focused on the non-clinical aspects that impact medical care but that are arguably as important as the clinical disease. The inclusion of Community Health Workers into the management of patients serves to broaden our collective definition of care management and to create interventions and assessments that incorporate social determinants of health. This expanded approach has helped in the success of ACOs by providing an enhanced understanding how the patient interacts with their disease and the health care system. 


  1. J. Michael McWilliams, Michael E. Chernew, and Bruce E. Landon, “Medicare ACO Program Savings Not Tied To Preventable Hospitalizations Or Concentrated Among High-Risk Patients”, HEALTH AFFAIRS 36, NO. 12 (2017): 2085–2093.
  2. Lonny Reisman, “A Broken System: Why High-Risk Patients Aren’t Benefiting from Value-Based Care”, Accountable Care News, Volume 9 Issue 2, February 2018.

submitted by Kirsten Anderson MD, MPH, Chief Medical Officer for Value Care Alliance, to Accountable Care News

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