Despite scientific and medical advances, it’s becoming increasingly difficult to meet Americans’ health care needs as the population ages and as the number of people with multiple chronic conditions continues to rise.1 Adding to the complexity is that nearly one-third of U.S. adults with medical conditions also suffer from mental health disorders.

A large portion of U.S. health care spending goes to the care of high-need, high-cost patients—those with clinically complex conditions, cognitive or physical limitations, or behavioral health problems that contribute to outsized use of health care services. In fact, 5 percent of patients account for half of the nation’s health care expenditures. Only by developing and adopting new models of care for our sickest and frailest patients, and by preventing the chronic conditions that lead to high costs,2  can we help people live healthier lives and conserve precious health care dollars.

Fortunately, several pioneering health systems have developed care models that improve outcomes for complex patients while lowering the cost of care. The Affordable Care Act has also opened up opportunities to identify and spread alternative ways of delivering and paying for care, thereby improving its value. But several barriers—such as the prevailing fee-for-service payment system and fragmentation of services—stand in the way. What’s needed is a strategic vision that could help health system leaders navigate these barriers, select new care models, and knit them into a coherent approach that improves quality while containing costs.

Here are six principles based on improving value both for patients and health systems. These principles build on the work of The Commonwealth Fund’s Commission on a High Performance Health System, which in 2009 provided a useful roadmap for reforming how U.S. health care is delivered and organized. They also reflect a recognition that the path to improving care for complex patients—and for all Americans—may require a new and different compass.

  1. Identify subgroups of patients with similar needs and challenges. High-need, high-cost patients are a diverse group, ranging from homeless adults with schizophrenia to frail elderly living alone. An important starting point is the identification of subtypes, or segments, of patients with common needs to facilitate the design and implementation of effective interventions. Subgroup descriptions should consider patients’ behavioral and social service needs, as well as their medical conditions.
  2. Shift the delivery of care for high-need patients from institutional settings to home and community settings whenever possible. Institutional settings frequently fail to meet the needs of patients and caregivers and may be both risky and expensive. Home and community settings are familiar and comfortable for patients and caregivers, and may be less hazardous if properly managed.
  3. Build the capacity to assess and actively manage social and behavioral health needs in addition to medical needs. Integrating medical, behavioral, and social services requires more than simply improving communication among the traditional siloed agencies and professionals. Multidisciplinary teams of clinicians, behaviorists, case managers, and patients working together can better tailor treatment plans to address medical needs by managing behavioral health conditions such as severe depression and non-medical issues such as unstable housing.
  4. Make it easier for patients, caregivers, and professionals to work in close coordination with one another. Patients want their doctors and other providers to talk to each other, and they want in on the conversation. While many strategies exist, the health care, behavioral health, and social service enterprise could improve communication by taking full advantage of advances in consumer-friendly digital options such as secure texting, email, remote access tools (e.g., telehealth), and social media platforms.
  5. Design and deliver services that meet goals set collaboratively by patients, caregivers, and providers. Evidence suggests that patients and physicians differ in what outcomes they view as most important. Goals developed collaboratively are more likely to be driven by patients’ needs—such as attending a child’s wedding out of state, not just reduced blood sugar levels—and have a greater chance of being achieved. 
  6. Allocate resources based on the potential to have a positive impact on the quality of life of patients and caregivers. Existing payment systems based on historical insurance coding schemes, service definitions, settings, and institutions are inflexible. If providers understand high-impact services, and can allocate resources as needed under a per-patient or outcomes-based payment system, they will be able to offer comprehensive services that can reduce health care spending and improve the lives of very sick, frail patients. 

We believe that initiatives that are consistent with these six principles will produce better outcomes at lower cost for high-need, high-cost patients. Over the next few years, The Commonwealth Fund’s Health Care Delivery System Reform Program will be dedicated to working collaboratively with other organizations to assist in the design, selection, implementation, and evaluation of these efforts to improve care for our nation’s sickest and frailest individuals.



1 U.S. Department of Health and Human Services, Multiple Chronic Conditions—A Strategic Framework: Optimum Health and Quality of Life for Individuals with Multiple Chronic Conditions (Washington, D.C.: DHHS, Dec. 2010); and S. Goodell, B. G. Druss, and E. Reisinger Walker, Mental Health and Medical Comorbidity (Princeton, N.J.: Robert Wood Johnson Foundation, 2011).

2 S. B. Cohen and W. Yu, The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008-2009, Statistical Brief (Rockville, Md.: Agency for Healthcare Research and Quality, Jan. 2012). >