Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Abstract

Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.

Conflict of interest statement

Dr. Hochman co-directs a clinician training program in partnership with CareMore, one of the health care delivery organizations highlighted in this article. There are no other conflicts of interest to report.

Figures

Figure 1

Stratification of health risk within a population. Patients with “severe health risk” represent the 5–20% of the primary care population with the highest needs and costs. These are the patients most likely to benefit from intensive primary care services. Standard continuity primary care works best for those with moderate to high risk. The majority of the population, who are at low health risk, require only routine preventative care and episodic low acuity acute care.