Developing an actionable patient taxonomy to understand and characterize high-cost Medicare patients

Abstract

Background: Improving care for high-cost patients requires a better understanding of their characteristics and the ability to effectively target interventions. We developed an actionable taxonomy with clinically meaningful patient categories for high-cost Medicare patients-those in the top 10% of total costs.

Methods: A cross-sectional study of a Medicare fee-for-service (FFS) patient cohort in the New York metropolitan area. We merged claims and neighborhood social determinants of health data to map patients into actionable categories.

Results: Among 428,024 Medicare FFS patients, we mapped the 42,802 high-cost patients into ten overlapping categories, including: multiple chronic conditions, seriously ill, frail, serious mental illness, single condition with high pharmacy cost, chronic pain, end-stage renal disease (ESRD), single high-cost chronic condition, opioid use disorder, and socially vulnerable. Most high-cost patients had multiple chronic conditions (97.4%), followed by serious illness (53.7%) and frailty (48.9%). Patients with ESRD, who were seriously ill, and who were frail were more likely to be high-cost compared to patients in other categories. 72.7% of high-cost patients fell into multiple categories.

Conclusions: High-cost patients are highly heterogeneous. A patient taxonomy incorporating medical, behavioral, and social characteristics may help providers better understand their characteristics and health needs.

Implications: Mapping high-cost patients into clinically meaningful and actionable categories that incorporate medical, behavioral, and social factors could help health systems target interventions. Integrated approaches, including medical care, behavioral health, and social services may be needed to effectively and efficiently care for high-cost patients.

Keywords: Case management; Health care delivery; Implementation research; Quality improvement; Utilization.