Population Segmentation and Targeting of Health Care Resources: Findings from a Literature Review

Working Paper 58
Publisher: Washington, DC: Mathematica Policy Research
Dec 01, 2017
Dana Jean-Baptiste, Ann O'Malley, and Tanya Shah

Key Findings:

  • Predictive analytics or quantitative claims data alone are not sufficient to inform segmentation or the timely tailoring of care to patient subgroups. The incorporation of clinical judgment, data from the electronic health record, health risk assessments, and interviews with patients requires time, but is vital to segmentation and the tailoring of health care resources to subgroups. Segmentation and efforts to tailor health care resources also need to consider the amenability of patients’ conditions to treatment and patients’ willingness to engage in recommended care or care management activities.
  • Using an iterative process to segment HNHC patients into subgroups is important, both because organizations are constantly improving their segmentation approaches over time and because patient risk factors and health status change with time.
  • Only a few of the articles reviewed noted how programs specifically tailor health care resources to each of the subgroups they identified. More typically, articles listed the general types of services available to patients deemed high risk, regardless of subgroup.
  • Future work could examine the extent to which organizations find it feasible to create subgroup-specific care paths and resources versus simply using segmentation results to decide whether to assign patient subgroups to enhanced care management. 
Health care costs have grown steadily over the years, and a large percentage of these costs can be attributed to patients with multiple, complex health care needs. Studies note that while these “high-need, high-cost” (HNHC) patients make up to 5 percent of all patients in the nation, they account for nearly half of health care spending in a given year. Some health care organizations, particularly those taking on increased financial risk for their patients, are turning to population segmentation to help address this issue. Population segmentation is key to efficiently targeting resources to the highest-risk, and potentially most costly, patients in health care organizations to improve quality of life and maximize efficient use of health care resources. This paper reviewed the literature to identify health care delivery organizations’ approaches to segmenting their HNHC patients and using that information to tailor health care services to meet their patients’ care needs. Health care delivery organizations most commonly used a hybrid approach, combining both quantitative (for example, claims) and qualitative (for example, clinician judgment) sources of data. Most tailoring of resources concerned either enrolling a patient with a nurse care manager and/or arranging for necessary social supports (for example, housing and food) that impacted patients’ health.