Targeted approaches to improve outcomes for highest-cost patients.

Bash and colleagues, using data from Maccabi Healthcare Services, have documented increased cost and utilization attributable to patients with congestive heart failure (CHF). The CHF patients were older than the general population and had high rates of important comorbid conditions. While it is somewhat predictable that such a population would have higher healthcare utilization and costs, the extent of the difference was still surprising. Most CHF patients (78%) were hospitalized at least once, compared to only 21% of patients without CHF. CHF patients used dramatically more of every kind of health care, including physician visits, emergency department visits, and specialty care visits. In this paper, Bash and colleagues have provided essential information about the "cost epidemiology" of CHF patients in the Israeli context. This commentary places these results in a broader context of how "cost epidemiology" information can be translated into targeted programs to improve outcomes and costs for vulnerable populations. The commentary makes three key points. First, beyond showing the increased utilization and cost attributable to CHF, there is also a need to examine which patients within this broad category contribute most to these increased costs, and might therefore be targeted for enhanced services. Second, it is helpful to make a business case for intervening to improve outcomes with a subpopulation, focusing in particular on the return on investment from the standpoint of the payer. Finally, while Israeli health collectives have already deployed programs to improve outcomes in older and sicker patients, there may be a need to more precisely define important subpopulations based on social risk factors or particularly severe disease manifestations, and then target those subpopulations with tailored programs focused on their particular needs.