57
Chapter 4
Assessing the
Community and the
Patient Population
As we look to create a new care subsystem for our
poly-chronics, we must first select a population of patients
to care for, understand their care needs, and develop care
strategies to be implemented to achieve the Five Pillars. This
will lead us to the proper selection and allocation of the
community resource pool, which will provide both the care
and the necessary physical plant and technologies. We will
then dynamically match the demand from the patients we
intend to serve with the capacity we create.
Selecting Patients
Chronic conditions are, of course, closely linked to high expen-
diture levels. More than 75 percent of high-cost beneficiaries
(the 25 percent of Medicare beneficiaries with the highest
costs) had one or more of seven major chronic conditions,
according to the Congressional Budget Office.
1
“The elderly and
58 ◾  Developing a Poly-Chronic Care Network
disabled, who constituted around 25 percent of the Medicaid
population, accounted for about 70 percent of Medicaid spend-
ing on services in 2003. People with disabilities accounted for
43 percent of Medicaid spending and the elderly for 26 percent.
The remaining 75 percent of the Medicaid population,who were
not elderly or disabled, accounted for only 30 percent of spend-
ing.
2,3
This may be due to several socioeconomic factors and
the patients typically enrolled in Medicaid programs.
The patients in your poly-chronic population will likely
come from private payors and from Medicare, Medicaid,
and dual eligibles. It might be surprising to find that the major-
ity of poly-chronics are currently insured in the private market
(65 percent)
4
and not through purely government programs
(31percent)
5
. Poly-chronics are typically 45 years old and
older, and may or may not end up in government insurance
programs later in life, depending on contractual agreements
with unions and employers that currently sponsor their care.
Of course, the sponsors of Medicare/Medicaid (i.e., tax-
payers) are quite interested in the reduction of costs for the
poly-chronics as so many are cared for via these programs.
Of the three groups (privately insured, Medicare, and
Medicaid), Medicaid patients are by far the most costly. This is
why you might find your payors (state, federal, and private) to
be ready partners in your cost-reduction efforts, as the state of
Vermont has seen with its care management programs.
In an ideal scenario, we would simultaneously determine
the patients to be served as we determine the available and
willing resource pool. This would save total implementa-
tion time and allow for an ongoing match between demand
(patients) and capacity (resources). It would also avoid a
complete or partial rework of the applicable patient popula-
tion if severe limitations in the resource pool are discovered,
and vice versa. For the sake of this discussion, however, I will
not make the assumption that this is possible, as you may
encounter resource, focus, and/or time constraints in your
implementation team.

Get Developing a Poly-Chronic Care Network now with O’Reilly online learning.

O’Reilly members experience live online training, plus books, videos, and digital content from 200+ publishers.