Bending the Cost Curve on High Risk Patients

Guidehouse's Christopher Stanley, M.D. via Modern Healthcare

It's well known that just a small group of risky members makes up the lion's share of total costs in the U.S. healthcare system. In Medicaid alone, the most expensive five percent of beneficiaries accounted for roughly 50 percent of all program spending, according to a 2015 Government Accountability Office study. And while nearly all plans have some kind of program aimed at managing high-risk patients, not all of them are able to successfully reduce costs.

Health plans managing high-risk Medicaid and Medicare Advantage beneficiaries are coming up with innovative ways to reduce costs and improve care, especially by addressing social determinants of health.

Partnering with healthcare providers is key to creating patient buy-in. Many health plans have realized that the trust factor with health plans and patients is not particularly strong. Different populations require different interventions. What works for controlling spending among Medicaid members likely won't be effective for a Medicare Advantage population. While Medicaid members tend to face barriers related to social determinants, Medicare Advantage members typically have several co-morbid conditions.

Christopher Stanley, Director, Guidehouse via Modern Healthcare

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