Preventing tomorrow's high-cost claims: the rising-risk patient opportunity in Medicaid

This commentary notes the superiority of targeting rising-risk patients rather than high-cost claimants for Medicaid cost containment based on analysis of 13.1 million beneficiaries across 15 states. In 2019, spending for rising-risk patients (13.6% of sample) increased by 98.5% whereas spending for high-cost claimants (0.64%) decreased by 41.6%. Significantly, 54% of high-cost claimants in the first half of 2019 fell below the cost threshold in the second half of the year, and 50% of new high-cost claimants were previously identified as rising risk. Our findings reveal the limitations of focusing solely on high-cost claimants, whose costs naturally decrease due to regression to the mean. We argue that Medicaid programs should shift from reactive, cost-management interventions to proactive, prevention-oriented outreach, particularly as new predictive algorithms become more sensitive and specific. Early identification of and intervention for rising-risk patients is a more effective way to prevent the progression of chronic conditions and manage associated costs than attempting to reduce extreme utilization, which tends to decrease naturally over time.