There’s even an acronym for them: HNHC, which stands for those high-need, high-cost patients who it’s estimated make up only 5% of U.S. patients but account for about 50% of healthcare spending.
And while lots of studies have focused on how to manage these patients, researchers at Weill Cornell Medicine in New York City decided to take a different approach. They asked the patients themselves how doctors and healthcare systems can best meet their needs and, in the process, cut costs.
The results were published in NEJM Catalyst and offered five solutions for reducing the high healthcare use among this group of patients.
The study is unique because it highlights that the patient voice is critically important in understanding how to deliver healthcare to the highest-cost patients.
“I’ve become increasingly aware and convinced of the importance of patient engagement to improve the way we deliver healthcare,” lead author Rainu Kaushal, M.D., a professor and chair of healthcare policy and research at Weill Cornell Medicine said in an interview with Fierce Healthcare.
Kaushal recently received an award from the Patient Centered Outcomes Research Institute (PCORI) and has been working with a newly established consortium of 22 organizations, including medical schools and universities, to create a central data resource to electronically share clinical data across New York City.
What patients are saying
Early research from Kaushal shows patients have a distinct voice and should be able to relay what is required from the healthcare system, thereby providing personalized medicine.
“The patient voice is so critically important,” said Kaushal, who is chief of healthcare policy and research at New York-Presbyterian Hospital/Weill Cornell Medical Center.
These aren’t easy patients to care for. High-need, high-cost patients often have multiple chronic conditions, complex psychosocial needs and limited ability to perform activities of daily living, the researchers noted.
Yet care delivery solutions—ranging from care management to home health visits—have had mixed levels of success both when it comes to system-centric measures such as emergency department use and inpatient hospitalizations and patient-centered measures such as their assessment of their own health status.
“A possible explanation for the variable success could be that many solutions are designed primarily by health system administrators, not the patient ‘customers’ who best understand their own needs,” the researchers wrote.
To learn what the patients needed to help them stay healthy, the Weill Cornell researchers, along with counterparts at the University of Florida, held focus group discussions with 21 patients and three caregivers from across New York and Florida. “I think they had some very interesting solutions,” Kaushal said.
The patients ranged in age from 23 to 80 and were racially diverse. In the prior 12 months, the patients had on average visited their primary care doctors six times, the emergency department 16 times and been hospitalized five times. Their medical conditions included arthritis, diabetes, asthma, heart disease, chronic obstructive pulmonary disease, obesity, epilepsy, hypertension and depression.
Here’s five of the top solutions the patients suggested to improve their care and reduce costs:
Care management. Patients appreciated help with appointment scheduling and reminders. They said care managers are trustworthy partners in their day-to-day care, available to talk to them and answer their questions. “While the jury is still out on the return on investment of care management—in terms of utilization and outcomes—the patients in our focus group were convinced of its benefits,” the researchers wrote.
Readily available at-home physical therapy and nursing services. This is particularly valuable after stays in the hospital or rehab centers. Patients with mobility restrictions or transportation challenges, especially appreciated home-based services.
More after-hours clinics. Patients said that would be crucial to reducing reliance on the emergency department, especially if the clinics were conveniently located. While these after-hour clinics exist, doctors and hospitals can do a better job advertising and promoting these clinics, Kaushal said. Doctors can help educate patients about when to use these clinics instead of urgent care centers or the emergency room.
Telemedicine. Kaushal said she was surprised how open patients were to the use of telemedicine. Some patients said the ability to communicate with a provider could answer their questions and reduce anxiety that often resulted in visits to the emergency room. Patients suggested telemedicine could help provide behavioral health services. Doctors can better educate patients about when telemedicine might be a good alternative to an office visit.
Home delivery of prescription medications and easier refills. Patients said they were sometimes unable to pick up prescriptions and appreciated home delivery of medications. Some also said having a larger supply per refill cycle would be better, for instance getting a 90-day prescription instead of the typical 30-day supply. Several pharmacy groups are piloting automatic monthly refills and home delivery of prescription medications, and these services should be more widespread and better publicized, the researchers said.
Almost all of the solutions advocated by patients are being tried in various healthcare settings, but the researchers said healthcare systems should look at putting more resources into implementing these ideas.
While patients focused on medical needs, few talked about social factors that can influence health, such as having safe housing and nutritional food, Kaushal said. She speculated that may have been because the questions were being asked by healthcare providers in a medical setting.