The NCSL Blog


By Richard Cauchi

Half of medical expenditures in the U.S. can be attributed to about 5 percent of the nation’s patients—those with high health care needs.

Doctor examining options on screenImproving and integrating care for patients with multiple conditions and diseases can help both patients and payers, including taxpayers, especially for those enrolled in Medicaid and Medicare programs.

On Dec. 8, The Commonwealth Fund President Dr. David Blumenthal addressed attendees at the NCSL Capitol Forum on both the challenges states face with high-need, high-cost patients and about strategies states can undertake to improve patient care and save money in their Medicaid programs.

Blumenthal, previously a practicing primary care physician and professor of medicine and health policy at Massachusetts General Hospital and Harvard Medical School, noted that high-needs adults tend to be older, have low socio-economic status and have public insurance, notably Medicaid and Medicare.

For the state policymakers, he moved quickly to What works?”

A five-point strategy includes: 

  • Stratify patients by common needs.
  • Invest in care coordination.
  • Shift care from institutions to community.
  • Integrate medical, behavioral, and social services.
  • Give providers flexibility in allocating resources.

Two states 1,200 miles apart provide examples of successes in controlling costs while improving care experiences.  

In Massachusetts, the Commonwealth Care Alliance has more than 60 sites and serves 17,000 disabled adults and frail elders. It reduces hospital and nursing home use using patient-friendly primary care teams with home visits. 

In Minnesota, Hennepin Health is a Safety-net Accountable Care Organization (ACO) serving 10,000 plus Medicaid patients. It is a partnership among county health department and medical center, county-run health plan, and federally qualified health center. They integrate medical and social services, using community health workers; complex patients are referred to an ambulatory ICU clinic instead of emergency rooms. . 

National Survey

A new national Survey of High-Need Patients released by The Commonwealth Fund in mid-December, shows that in many settings “the U.S. health system is failing to deliver high-quality, coordinated care to [high needs] patients.”

Survey results indicate that “high-need patients have greater unmet behavioral health and social issues than do other adults and require greater support to help manage their complex medical and nonmedical requirements.”

According to the survey, less than half of high-need adults receive assistance in managing conditions. Nearly half (48 percent) of high-need respondents were hospitalized overnight in the past two years; a similar percentage (47 percent) went to the emergency department multiple times in the past two years; 19 percent used the emergency department for a condition that could have been treated in a doctor’s office or a clinic.

New State Tool

The Playbook: Better Care for People with Complex Needs, developed by the Institute for Healthcare Improvement, was launched in mid-December.  It offers examples of successful approaches to care, guidance on making the business case for investing in these models and opportunities for policy and payment reform.  A connected brief provides examples from 32 states and Puerto Rico.

Related Resources

Map of complex needs population

Brown-colored states have programs.

Source: Map by Center for Health Care Strategies 2016

Richard Cauchi is a program director in NCSL’s Health program.

Email Richard

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.