Patient segmentation divides populations into distinct groups—each with specific needs, characteristics, or behaviors. Doing so allows care delivery and policies to be tailored for each group. The idea of patient segmentation is not new, for example, the cancer model segments care from the general population. However, combining demographics, care patterns, and patient status, we can find new opportunities to tailor care for groups of individuals. Doing so drives engagement because it informs providers how to better understand their patients .

Access to More Care through New Plans and Partnerships

When we think about patient segmentation it is typical to group patients by diagnoses or risk categories. This has been the general practice since patient segmentation initially became popular in the 1970s. Care providers are challenging this traditional line of thinking by segmenting patients based on care patterns instead of single events or diagnoses. Health plans are reacting to this shift and are adjusting to reach new members.

Clever Care, a Southern California-based Medicare Advantage health plan, grew significantly in the Asian community by focusing on benefit offerings through a grassroots model that engaged community members. This gives members access to Western standards of care in addition to Eastern practices, that were previously not covered. Clever Care projected its year-over-year membership to increase tenfold following the 2022 annual enrollment period. Similarly, Alignment Healthcare began serving members through its “el Unico” option focused on the Hispanic population. This improves access to healthcare by expanding two of its HMO plans that are tailored toward Asian and Hispanic populations.

The SCAN Health Plan partnered with Included Health to launch its Affirm product focusing on the LGBTQ+ community. SCAN Affirm members will be supported by Included Health’s Communities program, a leading healthcare navigation platform for underserved populations. The platform improves care equity by increasing members’ trust in healthcare, connections to high-quality affirming care, and healthcare literacy, while reducing care avoidance. Members will have access to culturally-affirming behavioral health and on-demand virtual visits.

What these products have in common is that they provide differentiated services and benefits. They also unlock growth that might not otherwise be attracted to the market or the company. Zocalo Health, for example, is a new clinical company founded by Amazon Care alumni Erik Cardenas and Mariza Hardin “by Latinos for Latinos.” As these trends continue, providers will have access to diverse communities that have similar needs. Adjusting care based on these needs drives consumer engagement.

Patient Segmentation Adds Value to Strategy

When patients are segmented by need they are provided better care and opportunities for health improvement. Johns Hopkins has adapted this approach with their Adjusted Clinical Group (ACG) practice, which was updated in June of 2022,  Dr. Klaus Lemke from the Bloomberg School of Public Health says “We approach segmentation across the age spectrum based on health needs, financial risk and care opportunities. Our new segmentation feature — Patient Need Groups — expands the segmentation approach to the typical course of chronic diseases and gives focus to populations beyond the elderly and disabled. …Using the markers within the ACG System, we have created a segmentation model that includes the best from other models, while increasing focus on non-elderly and lower-risk populations.”

Integrating clinical and financial information allows care givers to incorporate many factors that impact care at the same time. These deeper insights help facilitate more efficient care and targeted clinical support. This means that care providers can design effective service models based on the population’s unique health needs. Doing so enables a range of analyses that discover opportunities within existing populations, which results in focused resources and specific actions for patients.

One Size Does Not Fit All

Segmentation plays a big role in care models, from image analysis to detection, classification and treatment. When we segment patients by current status and their potential status, physicians develop treatment plans that are more targeted to what a patient needs. As care providers overlap this line of thinking with segmentation about sub-populations and demographics, attention is paid to coordinating services creating “seamless care”. 

Researchers at the Center for Medicare and Medicaid Services, criticized a frequent approach used by service industries that stratify customers into groups by services they presently use. Examples are “nursing home clients” or “home help clients”, which limits the potential for new services.  As an alternative, the group proposes segmentation by “health prospects and priorities”, what a patient is currently experiencing and what their needs will be. This creates a patient focused view of care opportunities. They propose:
 

1. Limiting segmentation, so that groups are meaningful (and practical)
2. Segmentation needs to be inclusive of everyone that meets the group criteria
3. The people in each segment should have similar healthcare needs, rhythms of needs, and similar priorities
4. Segments should be sufficiently distinct

The research group suggests that following these guidelines support patient-focused segmentation that is timely, effective, efficient, and equitable. The result is a lower strain on the current healthcare systems because of the coordination of available care with projected needs using an algorithmic treatment approach rather than unstructured diagnosis and assessment.

“If we better understand our segments so we know what their preferences are and how they want to be engaged, we can become more aligned with their needs,” says Jesse Cureton, chief consumer officer at Novant Health. “The other side of that coin is about the clinical care. Better engagement correlates with our ability to provide better health care and ultimately improve the health of the communities that we are in.”