Ten Questions to Better Understand and Serve Your Complex Care Population


This policy brief highlights 10 questions health plans and systems nationwide could consider using in their risk assessments to deliver more cost-effective, quality care.

Date Updated: 04/02/2018

The CHRONIC Care Act and new CMS guidance promote assessment of functional and social needs as part of delivering more cost-effective, quality care to individuals with complex needs. This brief shares 10 questions required of California’s Medicaid managed care plans, which health plans and systems nationwide could consider for their risk assessment instruments.


Health systems often identify individuals as “high cost,” “high need,” and/or “high risk” by using administrative and clinical data captured as part of medical billing. These data include items such as diagnoses, emergency department utilization, and prescription drug costs. While this easily accessible, medically oriented information provides an initial snapshot of care complexity, research shows that non-medical factors – how a person functions on a daily basis and the extent of one’s social supports – significantly affect overall health care utilization and spending.1 In fact, it costs twice as much to care for older adults with chronic conditions and functional limitations compared to those with chronic conditions alone (Figure 1).2,3

To better understand the populations they serve and effectively organize care, leading health plans and accountable care organizations (ACOs) are beginning to gather person-level data about social determinants of health (i.e., access to food, housing). The risk assessment is a natural process point for health plans and ACOs to include questions that specifically capture an individual’s functional and social support needs. This new knowledge can provide a clearer understanding of a person’s total need profile, and how it affects their health status; improve population-level risk stratification; and support delivery system efforts that better match people who have identified needs with high-quality, targeted interventions.1

Federal policymakers are fueling this trend by promoting more comprehensive assessments and linking those with complex care needs to appropriate services inside and outside of health care.

Recent policy actions include the following:

  • In a draft Medicare Advantage and Part D 2019 Call Letter, federal officials recognized that health risk assessment (HRA) tools must assess beneficiaries for medical, functional, cognitive, psychosocial, and mental health needs. Medicare Advantage plans will be allowed to offer beneficiary incentives for HRA completion beginning in 2019.4
  • The Call Letter and the CHRONIC Care Act also expanded the scope of supplemental benefits in Medicare Advantage that beneficiaries could receive based on a comprehensive needs assessment.4,5

California has taken a major step in this regard, as the state recently required all Medicaid managed care programs to incorporate 10 questions in their HRA that evaluate for function and social support needs. As leaders in health plans, ACOs, and other risk-bearing entities revisit their assessment tools for better management of complex care populations, below are the 10 questions to consider for inclusion.

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In this paper, the National Committee for Quality Assurance (NCQA) discusses prior integration efforts; introduces a model for integrated entities and a framework for assessing and promoting quality of integrated care; and explores the challenges to implementing and achieving the goals of person-centered, integrated care for Medicare-Medicaid beneficiaries. They use the word “framework” to describe the key concepts underlying the structure and process measures; it can also be expanded to include the content of performance measures as companions to the structure and process measures.

To succeed in this era of health system transformation, plans and providers bearing risk – in an accountable care organization (ACO) for example – will need strategies for managing a broad array of care needs for high-risk beneficiaries across multiple settings of care. Download this fact sheet to learn more.

A white paper and series of briefs from Avalere Health produced with support from The SCAN Foundation explore the use of non-medical data to better coordinate care for high risk Medicare beneficiaries, which can lead to improvements in care while providing health plans a return on investment.