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Caring for High-Risk Patients Requires Meeting Social Needs and Addressing Barriers to Care

athenahealth unveiled data reinforcing the notion that addressing social determinants of health is a crucial part of care delivery, especially for high-risk patients. According to the findings, patients in low-income zip codes were less likely than patients in high-income zip codes to have scheduled an annual wellness visit within 90 days of eligibility. Closing this gap in care is a priority for primary care clinicians, and this difference underscores the challenges that patients in lower-income areas have with accessing care. The athenahealth findings are based on approximately seven million de-identified patients, 4.6 million of whom are high-risk, which is defined as having two or more chronic conditions. Specifically, the data show that:

    • 39% of high-risk patients in high-income zip codes (median household income >$70k) scheduled a wellness visit within 90 days of their eligibility.
    • 37% of high-risk patients in medium-income zip codes ($50-$70k) scheduled a wellness visit within 90 days of their eligibility.
    • 33% of high-risk patients in low-income zip codes (<$50k) scheduled a wellness visit within 90 days of their eligibility.

Overall, high-risk patients living in low-income zip codes were less likely to close care gaps than those living in high-income zip codes. However, these patients are often the ones who most need preventive care like annual wellness visits. According to the data, the highest-risk patients are more likely to be aged 60+, and after adjusting for age, are disproportionately likely to live in low-income zip codes and to identify as Black or African American. These patients often face systemic barriers to accessing care, including lack of insurance or difficulty obtaining time off from work for appointments, making it harder to get them in the door for an annual wellness visit. Exacerbating the situation, more care requires more out-of-pocket financial obligations, meaning that patients with chronic conditions end up with higher medical bills despite socioeconomic disadvantages.

“The problem that our health system faces today is that the sickest patients who most need continuous, consistent, preventive care often face not only challenges related to their illness, but systemic barriers to accessing care. The social determinants of health are also the social determinants of access,” said Jessica Sweeney-Platt, vice president of research and editorial strategy at athenahealth. “At athenahealth, we aim to unlock data across the healthcare ecosystem to generate actionable insights for our network of customers, and we hope these findings can help practitioners as they work to close care gaps for high-risk patients.”

Many practitioners surveyed as part of the analysis shared that patients often can’t make progress toward their health goals until their social needs are met. For example, a diabetes patient who also struggles with food and housing insecurity would not be able to focus on improving diet, exercise habits, and medication adherence without additional food assistance. As such, it is important to support patients as whole people and engage them with personal connections, supported by technology.

The analysis also identified a significantly lower care gap closure rate at Federally Qualified Health Centers (FQHCs) versus non-FQHC organizations. FQHCs typically serve communities that may not have easy access to an outpatient clinic and may be at a socioeconomic disadvantage in society.

The data does include some positive findings, however:

  • Overall, patients with chronic conditions were more likely to be on time for their wellness visits, and more likely to close wellness care gaps if they become overdue, than low-risk patients. Twenty-one percent of patients with chronic conditions closed their care gap, compared to 18% of those without.


The quantitative sample was based on approximately seven million patients assigned to a primary care provider’s panel as of 2020, and who had an annual wellness visit (AWV) in 2019 and were due for the next one in 2020. Regardless of payer type, most insurance plans reimburse for a wellness visit exactly one year after the last one. In the sample, 4.6 million of the patients were high-risk (defined as having two or more chronic conditions). Interviews were also conducted with clinicians and administrators at practices using athenahealth software to understand their perspectives on challenges, strategies that work, and infrastructure needed when it comes to delivering effective care to high-risk patients.