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Meeting the Challenge of the High-Need, High-Cost Population

Alan M. Jette
DOI: 10.2522/ptj.2016.96.11.1682 Published 1 November 2016
Alan M. Jette
A.M. Jette, PT, PhD, FAPTA, is editor in chief of PTJ.
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Health care in the United States faces critical challenges despite tremendous developments in medical science and care delivery, such as biomedical discoveries, new approaches to health care financing, and the rise of digital technologies.1 Although health care spending in the United States accounts for almost 18% of our gross domestic product—a rate considerably higher than all peer countries2—10% of the US population report their health as either poor or only fair.3 Rates of preventable chronic conditions continue to rise, contributing to poor health and increasing health care costs, and evidence-based strategies for prevention and management are poorly applied throughout the health care system.1

About 5% of adults in the United States (almost 12 million people) report having 3 or more chronic conditions and a functional limitation that makes it difficult for them to carry out daily activities.4 They account for almost half of US health care spending.5 Described as “high-need, high-cost” (HNHC), these individuals comprise our most complex patient population—one that has many needs that can best be met by physical therapists and other rehabilitation professionals. The HNHC population is diverse, consisting of people who are “frail 65+,” people who have disabilities, people who have advanced life-threatening illness, and community-dwelling people of all ages. This population all too often receives ineffective care, such as unnecessary hospitalizations.6

The presence of a functional limitation among the HNHC population can substantially increase health care utilization, cost, and the likelihood of receiving poor quality of care. Average annual health care spending is nearly 3 times higher for adults with multiple chronic conditions and functional limitations compared with adults with multiple chronic conditions only ($21,021 vs $7,577).4 With their functional limitations, the HNHC group is twice as likely to visit the emergency room and 3 times more likely to be hospitalized than adults with multiple chronic conditions only. Managing functional limitations—the central expertise of rehabilitation professionals—is an important consideration in the overall management of the HNHC patient population's needs. As reported in this issue by Kadivar and colleagues,7 providing optimal discharge disposition and follow-up services could prevent unplanned hospital readmissions. These investigators report that the odds of 30-day readmissions were 3.78 times greater when a physical therapist was absent from the discharge team compared with the odds of 30-day readmissions when a physical therapist participated. Despite their qualifications, physical therapists are infrequently represented on the interdisciplinary team.

Through an exciting Vital Directions initiative,1 the National Academy of Medicine (NAM) (formerly the Institute of Medicine) is assembling authoritative advice from the nation's foremost innovators to address the health needs of the United States, including the HNHC population. As Blumenthal and colleagues6 noted in their NAM discussion paper, the Affordable Care Act “offers an array of incentives and tools for pilot testing and refining alternative delivery and payment models, and many states and private payers have been experimenting with new approaches.” Increasingly, the shift toward value-based, population-oriented care encourages the participation of multiple providers, including physical therapists, to provide appropriate, high-quality care and to achieve improved outcomes in the HNHC population.

A number of care management models targeting the HNHC patient population have had promising results in improving quality of care, quality of life, and reducing unnecessary hospitalizations and costs.8 Existing evidence, though incomplete, indicates several common attributes seen in care management models that have proved to be successful, including9,10:

  • Close targeting of patients who are most likely to benefit from the services

  • Comprehensive assessment of patient needs

  • Specially trained care managers who facilitate coordination and communication among patient, family, and the care team

  • Interdisciplinary teamwork

  • Ability to manage patients' care across settings

However, because of the ongoing misalignment of health care resources in this country, widespread adoption of these programs has been retarded.6

Given that the HNHC population is certain to grow in the coming decades, it is imperative that physical therapists and other rehabilitation professionals support the adoption of innovative strategies such as comprehensive care management for this population.

  • © 2016 American Physical Therapy Association

References

  1. ↵
    1. Dzau VJ,
    2. McClellan M,
    3. McGinnis JM
    . Vital Directions for Health and Health Care: An Initiative of the National Academy of Medicine. JAMA. 2016;316:711–712.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Davis K,
    2. Stremikis K,
    3. Squires D,
    4. Schoen C
    . Mirror, Mirror on the Wall: How the US Health Care System Compares Internationally. 2014 Update. New York, NY: Commonwealth Fund; June 2014. Available at: http://www.commonwealthfund.org/∼/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf. Accessed October 4, 2016.
  3. ↵
    Centers for Medicare & Medicaid Services. National Health Expenditure Data–Historical. Available at: https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html. Accessed October 4, 2016.
  4. ↵
    1. Hayes S,
    2. Salzberg C,
    3. McCarthy D,
    4. et al
    . High-need, high-cost patients: who are they and how do they use health care? A population-based comparison of demographics, health care use, and expenditures. Issue Brief (Commonw Fund). 2016 Aug;26:1–14.
    OpenUrlPubMed
  5. ↵
    1. Cohen SB,
    2. Yu W
    . The Concentration and Persistence in the Level of Health Expenditures Over Time: Estimates for the U.S. Population, 2008–2009. Statistical Brief no. 354. Rockville, MD: Agency for Healthcare Research and Quality; 2012. Available at: https://meps.ahrq.gov/data_files/publications/st354/stat354.pdf. Accessed October 4, 2016.
  6. ↵
    1. Blumenthal D,
    2. Anderson G,
    3. Burke S,
    4. et al
    . Tailoring complex-care management, coordination, and integration for high need, high cost patients. Discussion paper. Washington, DC: National Academy of Medicine; 2016. Available at: https://nam.edu/tailoring-complex-care-management-coordination-and-integration-for-high-need-high-cost-patients-a-vital-direction-for-health-and-health-care/. Accessed October 4, 2016.
  7. ↵
    1. Kadivar Z,
    2. English A,
    3. Marx BD
    . Understanding the relationship between physical therapist participation in interdisciplinary rounds and hospital readmission rates: preliminary study. Phys Ther. 2016;96:1705–1713.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Bleich SN,
    2. Sherrod C,
    3. Chiang A,
    4. et al
    . Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Prev Chronic Dis. 2015;12:E197.
    OpenUrlPubMed
  9. ↵
    1. McCarthy D,
    2. Ryan J,
    3. Klein S
    . Models of care for high-need, high-cost patients: an evidence synthesis. Issue Brief (Commonw Fund). 2015 Oct;31:1–19.
    OpenUrlPubMed
  10. ↵
    1. Anderson GF,
    2. Ballreich J,
    3. Bleich S,
    4. et al
    . Attributes common to programs that successfully treat high-need, high-cost individuals. Am J Manag Care. 2015;21:e597–e600.
    OpenUrlPubMed
View Abstract
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Vol 96 Issue 11 Table of Contents
Physical Therapy: 96 (11)

Issue highlights

  • Physical Therapist Student Loan Debt
  • Exercise for Osteoarthritis of the Hip
  • Hospital-Based Outpatient Direct Access to Physical Therapist Services: Current Status in Wisconsin
  • Understanding the Relationship Between Physical Therapist Participation in Interdisciplinary Rounds and Hospital Readmission Rates: Preliminary Study
  • The 2015 Nepal Earthquake(s): Lessons Learned From the Disability and Rehabilitation Sector's Preparation for, and Response to, Natural Disasters
  • Icelandic Physical Therapists' Attitudes Toward Adoption of New Knowledge and Evidence-Based Practice: Cross-Sectional Web-Based Survey
  • Objective Gait and Balance Impairments Relate to Balance Confidence and Perceived Mobility in People With Parkinson Disease
  • Newly Identified Gait Patterns in Patients With Multiple Sclerosis May Be Related to Push-off Quality
  • Physical Rehabilitation Interventions for Post-mTBI Symptoms Lasting Greater Than 2 Weeks: Systematic Review
  • Fitkids Treadmill Test: Age- and Sex-Related Normative Values in Dutch Children and Adolescents
  • Joint-Specific Play Controller for Upper Extremity Therapy: Feasibility Study in Children With Wrist Impairment
  • Three Faces of Fragile X
  • Synergic Effects of Rehabilitation and Intravenous Infusion of Mesenchymal Stem Cells After Stroke in Rats
  • Structural Validity of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in People With Mild to Moderate Parkinson Disease
  • Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD
  • Measurement Properties of the Quebec Back Pain Disability Scale in Patients With Nonspecific Low Back Pain: Systematic Review
  • Outcome Measure Recommendations From the Spinal Cord Injury EDGE Task Force
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Meeting the Challenge of the High-Need, High-Cost Population
Alan M. Jette
Physical Therapy Nov 2016, 96 (11) 1682-1683; DOI: 10.2522/ptj.2016.96.11.1682

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Meeting the Challenge of the High-Need, High-Cost Population
Alan M. Jette
Physical Therapy Nov 2016, 96 (11) 1682-1683; DOI: 10.2522/ptj.2016.96.11.1682
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