Note: Publication by the NAM signifies that it is the product of a carefully considered process and is a useful contribution worthy of public attention, but does not represent formal endorsement of conclusions and recommendations by the NAM. The views presented in this publication are those of individual authors and do not represent formal consensus positions of the NAM; the National Academies of Sciences, Engineering, and Medicine; or the authors’ organizations.

July 6, 2017


New National Academy of Medicine Special Publication Offers Opportunities for Improving Outcomes and Reducing Costs in the Treatment of ‘High-Needs Patients’ – Those Who Make Up 5 Percent of All Patients but Account for Nearly Half of All Health Care Spending

WASHINGTON – Nearly half of the nation’s spending on health care is driven by 5 percent of patients, and improving health outcomes and curbing spending in health care will require identifying who these high-needs patients are and providing coordinated services through successful care models that link medical, behavioral, and community resources, says a new National Academy of Medicine special publication.  The needs of this population extend beyond care for their physical ailments to social and behavioral services that are often central to their overall well-being.  As a result, addressing clinical needs alone will not improve their health outcomes or reduce health care costs.  The publication—which summarizes presentations, discussions, and scientific literature from a three-part workshop series—examines the key characteristics of high-needs patients; the use of a patient categorization scheme, or a taxonomy, as a tool to inform and target care; promising care models and attributes to better serve high-needs patients; and areas of opportunity to support the spread and scale of evidence-based programs. 

“As the nation examines how to drive down the costs of health care, there are opportunities for action to improve the care and reduce the cost of delivering that care for one of the most expensive and challenging populations of the current health care system: high-needs patients,” said Victor J. Dzau, president of the National Academy of Medicine. 

“Improving the care management of high-needs patients—while balancing quality and associated costs—will require bold actions and system payment reform efforts by a broad range of stakeholders at multiple levels,” said Peter Long, chair of the planning committee for the NAM workshop series, and president and chief executive officer, Blue Shield of California Foundation.

Understanding the characteristics of high-needs patients is the first step in determining how to improve care.  However, consensus on those defining characteristics has been slow to evolve, the publication says.  While the high-needs population is diverse, three criteria could help define and identify this population: total accrued health care costs, intensity of care utilized for a given period of time, and functional limitations.  Functional limitations include limitations in activities of daily living—such as dressing, bathing, self-feeding, and grooming—or limitations in instrumental activities of daily living that support an independent lifestyle—such as housework, shopping, managing money, taking medications, or using transportation.

In terms of demographics, available literature indicates that high-needs individuals are disproportionately older and less educated.  They are also more likely to be publicly insured, have fair-to-poor self-reported health, and be susceptible to lack of coordination within the healthcare system.  Therefore, improving outcomes for this population requires assurance of attention to an individual’s functional, social, and behavioral needs—largely through social and community services.

Understanding how to care effectively for high-needs patients requires ascertainment of the key factors driving the needs for of each individual.  Because this patient population is heterogeneous, those factors will differ for different segments of the population.  Therefore, the use of a practical taxonomy that helps group individuals by the care they most need—as well as when, how, and how often they might need it—can inform decisions about how to serve these patients more effectively.

In the course of the workshop meetings, a taxonomy working group identified for discussion the taxonomic elements that might help align high-needs patients with the care models that target their specific circumstances.  While the success of even the best care model will depend on the particular needs and goals of the patient group a model intends to serve, which vary for different segments of high-needs patients, all successful care models aim to foster effectiveness across three domains: health and well-being, care utilization, and costs.  The planning committee identified 14 successful care models for high-needs patients and cross-referenced those models to the segments of the proposed taxonomy that could be served if health systems leaders could match the needs of their patients to appropriate models within this menu of evidence-based approaches.

A number of barriers currently prevent the spread or sustainability of successful care models including the misalignment between financial incentives and the services necessary to care for high-needs patients, health system fragmentation, workforce training issues, and disparate data systems that cannot easily share needed information.  The publication discusses these barriers as well as strategies for addressing them.

Overarching opportunities for action and reform identified in the publication include:

With funding from the Peterson Center on Healthcare, and in collaboration with the Harvard T.H. Chan School of Public Health, the Bipartisan Policy Center, and The Commonwealth Fund, the National Academy of Medicine convened this collaborative effort with health care leaders to accelerate improvements in the management of care for high-needs patients.  The views presented in this special publication are those of the authors and do not represent formal consensus positions of the NAM; the National Academies of Sciences, Engineering, and Medicine; or the authors’ organizations.

The National Academy of Medicine (NAM), established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.

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Leadership Consortium for a Value and Science-Driven Health System
Planning Committee for the Workshop Series on Models of Care for High-Need Patients

Peter V. Long (chair)
President and Chief Executive Officer
Blue Shield of California Foundation
San Francisco

Melinda K. Abrams
Vice President
Delivery System Reform
The Commonwealth Fund
New York City

Gerard F. Anderson
Center for Hospital Finance and Management
Johns Hopkins Bloomberg School of Public Health

Tim Engelhardt
Federal Coordinated Health Care Office
Centers for Medicare and Medicaid Services
Washington, D.C.

Jose Figueroa
Associate Physician
Brigham and Women’s Hospital, and
Instructor of Medicine
Harvard Medical School

Katherine Hayes
Director of Health Policy
Bipartisan Policy Center
Washington, D.C.

Frederick Isasi
Executive Director
Families USA
Washington, D.C.

Ashish K. Jha
Harvard Global Health Institute, and
Li Professor of International Health & Health Policy
Harvard T.H. Chan School of Public Health

David Meyers
Chief Medical Officer
Agency for Healthcare Research and Quality
Rockville, Md.

Arnold S. Milstein
Professor of Medicine and Director
Clinical Excellence Research Center and Center for Advanced Study in the Behavioral Sciences
Stanford University
Stanford, Calif.

Diane Stewart
Senior Director
Pacific Business Group on Health
San Francisco

Sandra Wilkniss
Health Division Program Director
National Governors Association Center for Best Practices
Washington, D.C.


Michael McGinnis
Executive Officer, National Academy of Medicine

Danielle Whicher
Senior Program Officer

Gwen Hughes
Senior Program Assistant