According to the Centers for Medicaid & Medicare Services, the U.S.’s national healthcare expenditure in 2021 clocked in at $4.3 trillion. Of that expense, 90% was directly attributed to chronic care. Chronic disease is expensive, and the country’s deepening health debt only promises to exacerbate costs.
The upside: 36% of total healthcare spending is composed of potentially preventable chronic care. An estimated $1.57 trillion could be saved annually by facilitating a reduction in reactive treatment through the closure of patient care gaps. In order to realize the full potential of this savings, healthcare organizations need a carefully designed, patient-centric gap closure strategy.
Finding the roots of noncompliance
Patient noncompliance is a common precursor to care gaps: An estimated 40% of patients do not adhere to their treatment regimen as instructed, and 50% of prescriptions for chronic conditions are taken incorrectly. A quarter of hospital and nursing home admissions result from noncompliance. Though this lack of adherence to medical recommendations is often assumed to be a conscious and intentional choice of the patient, the reality is it can arise from a variety of other, less controllable factors ranging from financial, geographical, logistical or psychological, to educational or temporal.
An important part of designing a successful strategy for gap closure is considering the root of the patient’s noncompliance. Healthcare organizations can then use that knowledge as a foundation to inform gap interventions.
The slope of intervention
In conjunction with factors of noncompliance, intervention efforts must account for the fact that all patients exist somewhere on a spectrum of health. On one end are those who are healthy, have good wellness habits, and follow physician recommendations; on the other, those with multiple, poorly managed chronic conditions. To have the greatest impact on outcomes, interventions must be tailored to address the patient’s clinical status and individual needs.
One way to look at this is through the “Slope of Intervention” model, a guide for aligning a patient’s position on the health spectrum to categories of intervention for targeted care gap closure.
Immediate correction: At the bottom of the slope are patients who are already experiencing a gap in their care. The gap could be minor, such as missing a preventative screening, or it could be major, like misusing a life-saving medication. In either case, these individuals carry a higher probability of requiring acute care or developing a chronic illness. As a result, they represent the largest risk in terms of health outcomes and financial impacts to health insurance payers, and therefore warrant swift intervention.
Ongoing adherence: Patients in this category have a long-term health condition for which they have a care plan and are managing their condition well. To help these individuals maintain their health and avoid slipping down into a more costly status, interventions should be aimed at supporting the patient in following their care plan.
Long-term prevention: These are individuals who are healthy, with no active illness, or those who may be at risk for developing a new condition. The objective here is to encourage continued alignment with healthcare best practices. Interventions targeted at patients in this category might include reminders for preventative screenings, tips for getting adequate exercise, or recommendations for mindful eating while traveling. Helping patients reach this part of the slope translates to a healthier population over time and offers substantial cost savings for insurers, as preventative services save 76% over reactive care expenses.
A four-phase, strategic approach to closing care gaps
1. Segment: Leverage available data sources to create an inventory of existing and potential gaps in care within your population, developing and prioritizing cohorts of patients with similar needs. Identify where these cohorts lie along the “Slope of Intervention” to determine what support these patients need to improve their health.
2. Ideate: Work to understand the needs and challenges facing patients in the cohort. Brainstorm potential interventions to reach those patients and close gaps. Using knowledge of their behaviors and preferences, identify ideal channels for engagement and optimize messaging for the greatest impact.
3. Plan: For each potential intervention, hypothesize and document the anticipated impact it will have for the patient and the organization. Based on those anticipated outcomes, prioritize interventions and build a roadmap to guide development. Define a measurement strategy to track outcomes and measure the success of each intervention.
4. Implement: Execute against the roadmap. Prepare the interventions as designed and optimize the selected channels for outreach. As interventions are launched, track their impact in the population following the defined measurement strategy. Analyze outcomes and iterate as necessary to maximize benefits to patients’ health and the organization’s return on investment.
More than one-third of spending on chronic ailments is preventable with proper healthcare guidance and practices. Through this patient-centered approach to engagement, organizations can systematically design, launch, and iteratively improve upon a care gap program in a very short amount of time to effect significant positive change in clinical outcomes and maximize financial savings.
Jake Leffler is a Solution Strategist for DMI.