WHAT IS THE FUTURE OF VALUE-BASED CARE?

Commercial risk will be a critical catalyst of progress – it’s complicated, but is it possible? We think so.

X
Our Take

Refining your approach to risk stratification

15 Minute Read

Risk stratification is the foundation of scalable population health management. Health care organizations often spend significant time and resources to identify their high- and rising-risk patient populations. However, despite these concerted efforts, many organizations find that those patient groups are still too large to inflect given finite clinical capacity and resources.

The most effective risk stratification takes a more nuanced approach: identifying highly actionable patients, not just high-risk patients.

 

The conventional wisdom

The need to prioritize finite resources and clinical capacity has been growing for years and increased during the Covid-19 crisis. In light of deferred care, organizations have a renewed urgency to identify patients who need increased access and services, such as care management.

To do this, most organizations stratify their patients according to the well-established population health risk pyramid. Organizations, especially those taking on risk, often target high-touch interventions at all high-risk and/or rising-risk patients with the goal of reducing avoidable utilization and the total cost of care.

 

Our take

Offering high-touch support to all at-risk patients often undermines efforts to reduce the total cost of care and spreads organizational resources too thin. Organizations need a more nuanced approach to risk stratification that recognizes some high-risk patients will always remain high-cost.

A more nuanced approach entails concentrating high-touch services on patients who are not just at-risk, but who also have inflectable risk factors. These “actionable” patients make up a subset of the high- and rising-risk categories on the population health pyramid. For example, one study found that just one-third of the 5% most expensive patients demonstrate cost savings through better care coordination and coaching.

When the goal of risk stratification is to identify “highly actionable” patients, not just high-risk patients, organizations can’t rely solely on utilization, cost, and disease state to prioritize the right patients for high-touch support. While these metrics are important for risk stratification, they cast too wide a net when used alone—and more importantly don’t reflect today’s patients, who are often more complex than their clinical condition.

The good news is that organizations don’t need to make inordinate IT investments or create the perfect data set to see anticipated cost savings from population health services.

 

Three low-cost steps to identify actionable patients

 

The future of value-based care

Medicare and Medicaid risk is progressing (slowly) – but commercial risk will determine whether the industry tips toward a new cost and quality standard.

  • Step

    Identify patients with risk factors you can inflect

    Read More Collapse
  • Step

    Focus new data collection on metrics that predict future demand

    Read More Collapse
  • Step

    Capture actionable patients who are not coming in for care

    Read More Collapse
 

Parting thoughts

Risk stratification strategies will continuously evolve,along with our growing understanding of patient complexity. 

How we understand the term “risk” is evolving—from clinical factors, to the addition of social complexity, to patients’ behavior and activation levels. Over the coming years, the criteria for what puts a patient at risk will continue to evolve, especially as we expand our thinking on health disparities, racial inequity, and social determinants of health. This continuous shift in how we identify patient risk underscores why risk stratification efforts have and will continue to be a population health challenge. Recognizing this, sustainable risk stratification today requires an iterative approach, developing alongside changing patient needs, organizational priorities, and IT capabilities.

In tandem with this evolving understanding of risk is the growing scope of what organizations can do to intervene in a patient’s progression up the risk pyramid. These interventions range from giving clinicians actionable guidance at the point of care to partnering with community organizations to tackle the root causes of what puts a patient at risk. Consequently, today’s organizations embracing value based care need to continuously re-evaluate not just patient identification efforts but also patient interventions—recognizing that risk stratification is only as effective as their ability to intervene to improve patient outcomes.

Have a Question?

x

Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.