Labeling Complex and Costly Patients as “Unimpactable”: A Morally Questionable Practice Likely to Worsen Inequities

To significantly improve value, health care systems and insurance plans have focused on the subset of individuals with complex chronic disease who have the worst outcomes and use the most care – the 5% of the population who use 50% of resources. In pursuit of efficiency, they have endeavored to direct resources and interventions to those individuals most likely to benefit from them. The broad term for this categorization – impactability – has little by way of explicit definition, research on efficacy, or simple discussion of the risks and benefits of using this taxonomy. Nonetheless, it has gained traction with the parties responsible for managing health care dollars. ¹ The term itself suggests a certain nobility around directing resources where they will have the greatest benefit. Yet, it also has significant risks. In this Point of View, we explore the potential for the categorization of individuals into the binary of impactable vs unimpactable to increase inequity and decrease innovation.

First, impactability is often found in partnership with other more concerning terms, including “unmanageability,” “co-operability,” or “motivation scores” – terms that shift the blame for treatment failure away from the interconnected systems that perpetuate those failures and on to the individuals themselves. One recent, high-profile article described an intervention predicated on the idea that one third of highly expensive patients are “people with severe chronic conditions who can't be returned to good health and require expensive treatment continually.” Accordingly, their intervention tweaked care as usual by simply adding a pharmacist and focusing on the third that were able to engage in care as the system had been built to provide it. ² Such discrimination robs resources and innovative energy from the very spaces where they are most desperately needed by writing off those who do not respond well to preexisting paradigms.

Meanwhile, categories of patients deemed “unlikely to respond to care” include mental health diagnoses, substance use disorders, housing instability, language factors, and even single parenthood. ³ Individuals who fall into these categories are the same ones who historically have suffered from stigmatization and marginalization by payment models that undervalue appropriate, evidence-based care through lower rates of reimbursement or narrower networks. Can we expect that the application of care management will yield better results when systems of care are under-resourced to begin with?

Furthermore, the poor outcomes in this group are disproportionately impacted by 4 domains. First, many factors that perpetuate poor outcomes related to chronic disease – social determinants of health – have not traditionally been systematically addressed by our health care system. Second, entrenched siloes separate key domains of human engagement: mental health, physical health, social services, criminal justice, and substance use disorder treatment. Lack of alignment across these domains further serves as a key impediment to improved outcomes. Third, equity of access to good care and outcomes is disparate related to ethnicity, race, and income. ⁴ Fourth, because the financial incentives for high-risk patients are often focused on formally attributed patients, companies might “cherry-pick” the patients they deem most impactable.

Digging deeper, individuals who do not engage in care as prescribed often have experienced trauma in their lives, along with discrimination and disrespect by health care systems, all of which contribute to diminished trust in and reasonable skepticism toward providers offering help. They may have attempted to improve their health and failed, exacerbating low self-esteem and diminishing the belief that they can impact their own outcomes for the better. Addressing health care concerns is often in competition with a range of issues in their lives that rightly take priority for both time and limited resources, like figuring out how to put food on the table for their children. Not only do we know that lack of resources significantly, negatively impacts intellectual and problem-solving capacity, ⁵ but the interplay between these different forces creates complexity that would be difficult for the most clear-minded individuals to solve on their own. Finally, as individuals fail to engage in care, procrastination and avoidance create a feedback loop of increasing anxiety and fear of facing their issues that can be difficult to escape.

Targeted resource allocation is an understandable response given the level of difficulty present in transforming entire systems compared with the comparably easier but smaller gains that can be realized by simply tweaking our systems as currently designed. Yet, our moral compass should guide us not to make absolute pronouncements about the fate of individuals. Instead, we must try – then keep trying – to innovate transformative solutions that solve for the very problems at the population level that lead to such categories in the first place. This will understandably take time, iteration, and learning, with the beginning of the journey populated by more failures than successes. As just one example, many in health care got excited about impacting so-called “hot-spotters” after initially heroic, impactful work out of Camden, New Jersey, only to see efforts to duplicate that work come up short. ⁶ This hasn't stopped entities such as the Robert Wood Johnson Foundation from continuing to fund new prototypes that build on lessons from past failures in pursuit of breakthroughs that will guide transformation in the future.

Consider the following case. A woman in her forties – let's call her Mary – struggles with obesity, diabetes, and pain. Mary has frequent emergency room visits, which often lead to inpatient admissions. She hasn't established consistent engagement with outpatient providers, which stems from multiple intertwined factors: single motherhood, alcohol use disorder, anxiety, and poverty, among others. She doesn't answer her phone when called by care managers. She is perceived to be disinterested or antagonistic when providers are giving education during her inpatient and emergency room visits. Over time, everyone from frontline providers, to care managers, to payers has written her off. As a result, Mary is likely to continue on the same path with worsening health outcomes and a continually diminishing quality of life. The feedback loop of mutual distrust and powerlessness prevents anyone from seeing a different path. Everyone in this case is struggling within a system that was set up as if none of these obstacles exists. As the famous quote attributed to W. Edwards Deming states: systems are perfectly designed to get the results they get. In this case – like so many cases – what we got was mistrust, cynicism, and hopelessness, each one a barrier to solving Mary's problems.

Our own health care system doesn't yet have the right answers, but we have started developing new roles, new strategies, and new pathways for engagement, determined to do better. Success will require several system-level changes: new payment mechanisms built to reward improving a population's health; effective mechanisms for addressing social determinants; integrating mental health and substance use disorder treatment across our entire health care system; and partnering with criminal justice systems and other settings that serve highly vulnerable populations to shift away from models that criminalize mental illness, substance use, and poverty. In each case, we must meet people where they are, take the time to build trust through loving relationships, then build self-esteem so that individuals believe they can succeed. We do not mean to suggest that this transformation can happen overnight. But it is simply not morally acceptable to expect any less, no matter how hard the journey is. Because we share a common humanity. Because everyone is impactable.