Patient risk stratification refers to categorizing patients based on their risk of developing certain health conditions, their likelihood of future healthcare utilization or costs, or their risk of other adverse outcomes. This process helps healthcare providers and payers identify high-risk patients and those most likely to benefit from early intervention and care management programs. By understanding a patient’s risk level, resources and efforts can be better targeted to improve outcomes and lower costs.
Importance of Risk Stratification
Risk stratification has become a key component of value-based care models that focus on keeping patients healthy while avoiding unnecessary healthcare expenditures. CoherentMI discusses major benefits of the effective risk stratification in Patient Risk Stratification Market as following:
- Predictive Analytics for Proactive Care: By analysing clinical, behavioural and social risk factors, providers can predict which patients may be at elevated risk in the coming years. This allows for proactive outreach and preventive care management strategies to be put in place before more serious or costly health issues develop. Catching issues early improves patient outcomes and lowers total cost of care over the long run.
- Targeted Resource Utilization: Healthcare organizations have limited resources for care management programs, disease management and patient engagement initiatives. Risk stratification ensures these programs focus on high-risk, high-need patients who will benefit the most. This targeted approach maximizes the return on investment from such programs.
- Population Health Management: Understanding the risk profile of an organization’s entire patient population is essential for successful population health management. It provides insight into where to focus community outreach efforts, identify gaps in care, and design supportive programs to address the needs of specific at-risk demographic groups.
Risk Stratification Methods
There are several commonly used methods and data sources for stratifying patients based on their health risks:
- Claims and Utilization Data: Analysing past medical claims, pharmacy claims and healthcare utilization patterns can reveal patients with multiple chronic conditions, frequent hospitalizations or emergency room visits. These patients are likely to continue being high users and costs in the future.
- Clinical Data and Diagnosis Codes: Pulling diagnostic codes and clinical metrics like lab values, test results, vital signs and symptoms from the electronic health record provides insight into a patient’s disease status and severity. Certain diagnoses and lab abnormalities point to higher future risks.
- Social Determinants of Health: Non-clinical factors like socioeconomic status, health behaviours, geographic location, transportation access and social support systems also impact health outcomes. Incorporating social risk screens and surveys adds context on life factors driving a patient’s overall risk level.
- Predictive Modelling and Machine Learning: By feeding vast amounts of claims, clinical, social and behavioural data into advanced algorithms, predictive models can be developed and refined over time to accurately anticipate short and long-term risks for an individual. As more data is collected on a population, the models become more precise.
- Risk Stratification in Practice: Once patients have been categorized into risk tiers based on their overall risk scores, healthcare organizations can implement stratified care management approaches tailored to each group’s needs.
- Higher Risk Patients: The highest risk patients are enrolled in intensive care management programs involving regular nursing outreach, complex care coordination, social services support and adherence monitoring. The focus is on avoiding admissions through proactive treatment of issues.
- Moderate Risk Patients: These patients receive disease management primarily through digital health tools, automated outreach and remote monitoring. Nurse support is provided as needed via telehealth. The goal is keeping chronic conditions stabilized to avoid escalation to high risk.
- Lower Risk Patients: For the lower risk majority who are generally healthy, emphasis is on preventive care, annual wellness visits, population health campaigns addressing social determinants, and patient engagement portals for basic questions. Risk of future issues is actively monitored.
Market Outlook
The global patient risk stratification marketis projected to grow substantially in the coming years according to research from CoherentMI. This growth can be attributed to rising healthcare costs, an aging population, increasing prevalence of chronic diseases, and value-based payment models incentivizing early intervention and proactive population health management. North America currently dominates the market owing to widespread adoption of advanced analytics, electronic health records, and reimbursement reforms in the United States driving investments in risk stratification technologies. However, Asia Pacific is emerging as a high growth region as developing healthcare markets focus on strengthening preventive care infrastructure and addressing growing disease burdens through data-driven risk profiling of patient populations.
