Nancy J. HamData-driven care management for high-risk populations is usually discussed in terms of clinical outcomes, but the systems that drive these efforts can also improve financial outcomes. In fact, poor compliance with care management guidelines is estimated to cost the U.S. healthcare system $290 billion a year.a

At their core, data-driven care management systems for high-risk populations include three key factors:

  • Population health analytics, including clinical risk stratification and advanced clinical decision support
  • Integrated care management work flows
  • Patient engagement tools that support holistic health management

Madhavi VemireddyIn this first part of a two-part series, we look at the role of population health analytics in driving cost savings. In part two, we will delve into the benefits of locally integrated care management models and patient engagement tools, and assess the financial impact of such tools.

In the past, patients were often treated episodically and in silos. Providers were paid based on the number of services provided, whether or not those services were necessary or successful. For example, a patient with chronic obstructive pulmonary disease may present at the emergency department several times a year because of issues that could have been prevented with a broader, more proactive care plan. Previously, that patient’s physician had no responsibility for the costs or outcomes.

But with the move toward value-based payment, that same physician could be penalized for not providing treatments to prevent costly readmissions. To avoid this risk, physicians are now turning to population health analytics and care management tools to help manage their patient panels. Using these tools, caregivers can easily develop treatment plans based on medical best practices.

Although population health at a broad level includes all individuals in a community, most costs come from a fairly small segment of that community. Consider these statistics:

  • Just 5 percent of the population accounts for nearly half of all healthcare costs.b
  • Thirty-five percent of low-risk patients will become moderate- or high-risk within a given year.c
  • Costs per patient for the highest-risk population range from $41,000 to $90,000. When comparing that group to the lowest-spending group, which averages just $236 per patient, it is easy to understand how improving the health of these populations can result in significant cost savings.d

Identifying these high-risk populations is the first step. Then you need real-time population health analytics to monitor the health status of the population. This information allows you to identify the full clinical profile of individual patients, including their health conditions, co-morbidities, and lifestyle risk factors, and prioritize the treatment plan according to the latest evidenced-based literature. With that critical information, a complete care plan can be delivered to the patient along with resources such as personalized patient education and digital coaching tools.

Clinical risk stratification and advanced clinical decision support (CDS) allow providers to match patients to the right clinical programs, and to focus on health improvement opportunities. For example, integrated clinical risk stratification and advanced CDS will identify high-risk patients with heart failure who would benefit from a nurse-led condition management program. This program could include a targeted, evidence-based action plan that identifies patients who are not taking an ACE inhibitor (the drug of choice for patients with heart failure to help prevent future hospitalization and coronary events). At the same time, a holistic action plan could be created to address all of the patient’s comorbidities, such as diabetes and high cholesterol. This approach includes an appropriate treatment plan that monitors pertinent lab information to manage conditions, and also monitors for issues such as potential drug side effects.

Advanced CDS for care plans that are appropriate for the individual reduces unnecessary hospitalizations and drives cost savings. One report estimates that using evidence-based guidance in clinical practice could reduce healthcare costs by $6 billion within 10 years.e

Nancy J. Ham, MIBS, is CEO of Medicity, A Healthagen Business, based in Salt Lake City. Twitter: @medicity

Madhavi Vemireddy, MD, is chief medical officer and head of product management of ActiveHealth Management, A Healthagen Business, based in New York City. Twitter: @ActiveHealthMgt


a. Health Intelligence Network, 2010 Benchmarks in Improving Medication Adherence.

b. National Institute for Health Care Management, The Concentration of Health Care Spending , July 2012.

c. Moore, T., “ The #1 Risk Stratification Mistake in Condition Management Programs,” WebMD, April 16, 2013.

d. National Institute for Health Care Management, The Concentration of Health Care Spending , July 2012.

e. The Commission on U.S. Federal Leadership in Health and Medicine: Charting Future Directions, A 21st Century Roadmap for Advancing America’s Health: The Path from Peril to Progress , Center for the Study of the Presidency and Congress, May 2010.

Publication Date: Tuesday, July 28, 2015