Preventing Tomorrow’s High-Cost Claims: The Rising-Risk Patient Opportunity in Medicaid

AJMC November 6, 2025
Sadiq Y. Patel, PhD, MSW, Harold A. Pollack, PhD, Sanjay Basu, MD, PhD

For Medicaid care management, focusing on rising-risk patients is more effective than targeting high-cost claimants, whose spending tends to decrease over time due to regression to the mean.

ABSTRACT

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...

Today's Sponsors

Today's Sponsor