Treating high-needs patients: Some health care practices have edge

Primary health care practices that treat a higher proportion of high-needs patients perform better on a range of spending and utilization measures, say researchers at the University of Michigan.

At the same time, smaller practices do a better job of caring for the high-needs patients, defined as those with two or more physical, mental or behavioral health concerns, they say.

Dori Cross, a doctoral candidate in the U-M School of Public Health, and colleagues found that practices in Michigan that treat more high-needs patients have lower spending, and these patients are less likely to visit the emergency room or face hospital readmission within 30 days of treatment.

Specifically, health care spending for high-needs patients is nearly 12 percent lower in moderate-size practices, in which these patients comprise 2-10 percent of those served, and 40 percent lower in larger practices with more than 10 percent.

"We think there could be a strong element of 'learning by doing'—practices that serve a higher proportion of high-needs patients become increasingly knowledgeable about how to address the many challenges impeding high-quality care for this population," Cross said.

"As high-needs patients comprise an ever-growing percentage of practice panels, a practice may reach a tipping point past which it makes sense to invest in the staffing, resources and care processes that are critical for addressing the distinct care needs of these patients."

The study in the March issue of Health Affairs analyzes the performance of Michigan primary care practices caring for commercially insured, high-needs patients, using data provided by Blue Cross-Blue Care of Michigan.

The researchers also found that the small practices of one or two physicians did not find significantly lower utilization despite lower spending.

"One possible explanation is that overall utilization is harder to reduce for this high-needs population given complex care needs," Cross said. "But, smaller practices may be doing a better job of preventing more serious declines in health status that result in significant healthcare spending within an encounter."

For example, Cross said, a patient admitted from a smaller practice may have fewer complications or a shorter stay, which translates into lower overall spending and better quality of care, even though the utilization may be the same.

"Our evidence suggests that a concentration of high-needs patients is needed for practices to make a targeted investment in resources and processes that better serve this population's care needs," Cross said. "Efforts to direct high-needs patients to specialized sites of care that serve a high proportion of these patients have shown early promise and could be bolstered with greater policymaker and payer support.

"Additionally, we are seeing a strong, consistent trend toward consolidation of primary care into large practices. If further research points in the same direction as our findings that suggest higher value care in smaller practices, policymakers need to consider ways to support and preserve the existing base of small practices across the country."

Julia Adler-Milstein, associate professor at the U-M School of Information and School of Public Health, also authored the study.