Using Segmentation and Data Analytics to Improve Care for High-Need, High-Cost Patients in Accountable Care Organizations


To better ensure that high-need, high-cost (HNHC) patients receive appropriate care tailored to their health needs, The Commonwealth Fund began working with Harvard's Ashish Jha, M.D., over three years ago to "segment" this population into clinically meaningful subgroups. Jha and his team defined six segments of the Medicare HNHC population: nonelderly disabled; frail elderly; major complex chronic; minor complex chronic; simple chronic; and relatively healthy (e.g., those who suffered a major acute event but have no chronic conditions). Panels of experts, including those participating in a series of workshops held at the National Academy of Medicine in 2015-16, informed and shaped this work. In July 2017, the Academy included this segmentation framework in its July 2017 report Effective Care for High-Need Patients. The next step is to test whether the framework can drive meaningful improvement in care delivery for HNHC patients in accountable care organizations (ACOs), which often struggle to manage the care provided to these individuals despite having the necessary incentives to do so. The project team will establish a collaborative of up to 15 ACOs to test and refine its segmentation approach. First, the team will work with individual ACOs to obtain their feedback on the approach and undertake iterative refinements. Building on this process, the researchers will then identify further subsegments of the HNHC population that ACOs ought to prioritize for the targeting of resources. The third aim will be to apply the refined segmentation and subsegmentation frameworks to individual ACOs' patient populations as well as the Medicare dataset to identify persistently high-cost subpopulations and the specific types of services that account for their high spending. By testing the application of the segmentation framework in a real-world setting, this project will yield practical insights for policymakers and health system leaders seeking to target care resources more effectively in ACOs and other risk-bearing payers and health care organizations.

Grant Details

Grantee Organization:
President and Fellows of Harvard College
Principal Investigator:
Ashish Jha, M.D., M.P.H.
Award Amount:
Approval Date:
November 14, 2017

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