Just five years ago, improving care and controlling costs for Medicaid’s most complex and expensive beneficiaries was far from a mainstream issue. Efforts to do so operated near the edge of health care innovation and far off the general public’s radar, serving small concentrations of individuals with highly complicated needs in isolated pockets across the country. The rationale for those investments was clear: a small subset of patients drove the majority of program costs, and many of these individuals had complex needs that made navigating a byzantine health care system nearly impossible. Small, innovative pilot programs began to emerge across the country, identifying and engaging those at greatest risk for high-utilization, and developing a set of best practices for how to improve care and deliver better outcomes at lower costs.
Fast-forward to 2015, and a “super-utilizer” groundswell is emerging. Programs designed to serve high-need, high-cost populations are growing in number – the Center for Health Care Strategies (CHCS) recently catalogued such programs in 26 states, and expects this number to steadily increase. In states that were operating small pilots five years ago (such as New York and Washington), statewide initiatives now serve tens of thousands of high-need, high-cost individuals every day. In other states and at the federal level, policymakers are increasingly making it a priority to launch and scale these programs. A number of foundations are aligning their strategies to further the field, and even the mainstream media are paying attention to who these patients are and what we need to do to rein in their costs.
When opportunity knocks this loudly, one has to wonder what’s driving all the attention. Here are a few key drivers we see:
1. There are new ways to pay for these models.
Despite current efforts toward value-based purchasing, the billable service is still the backbone of health care delivery. What providers can’t bill for, patients generally won’t receive. While the Affordable Care Act (ACA) is best known for its coverage expansions, it has also promoted powerful new tools (such as health homes) that enable states and their delivery system partners to pay for critical services like care coordination that previously were hard to reimburse, thus near impossible to scale. The ACA’s shared savings programs provide additional incentives for providers to invest in these models – since those who participate in these payment arrangements have new skin in the game to manage costs and reduce avoidable admissions, particularly for the highest-utilizers.
2. The stakes are getting higher.
At 70 million beneficiaries and growing, Medicaid is the largest health insurance program in the country, fully funded by taxpayers. Limited state and federal budgets have kept Medicaid under pressure since its inception, but growing enrollment post-Medicaid expansion will raise the level of public scrutiny on how to ensure program cost-effectiveness and sustainability. It is like the old-time bank robber Willie Sutton said when asked why he robbed banks: “because that’s where the money is.” With five percent of the population driving more than 50 percent of all spending, eyes are increasingly focused on Medicaid’s highest utilizers.
3. People are much more aware of the impact of mental illness and substance use.
The data are undeniable: mental health and substance use disorders are hugely present among super utilizers. Recent studies in Pennsylvania and New Jersey demonstrate these conditions are frequently the primary drivers of admissions among high utilizers, and that as many as three out of four high-utilizers have a behavioral health need. These data, along with new requirements for treatment parity and for benefit coverage under Medicaid expansion, are giving behavioral health a more prominent role in efforts to improve approaches to care for super-utilizers. These new efforts offer great promise for improving the system’s capacity to treat these pressing needs.
4. Appreciation is growing for the social determinants of health.
Whether framed as total health, a culture of health, whole person care, or otherwise, there is growing recognition that health care is only one small component of the forces that drive health. Nowhere is this more true than for individuals living below or near the poverty line, where access to safe and affordable housing, nutritious food, transportation, and many other basic services can be precarious at best. Programs serving high-need, high-cost populations have long recognized that social factors are often the root cause of “super utilization” – and are already redefining the boundaries of what constitutes health care in order to reduce costs among this cohort.
5. The evidence base is growing.
Thanks to efforts on the front-lines by a growing cadre of relentlessly innovative providers, we have an increasing understanding of how to do this work well. We have new care models, predictive analytics, consumer engagement strategies, and approaches to measuring quality – and are slowly building a body of literature (both peer-reviewed and “gray”) that can support the efforts of new organizations standing up their own super-utilizer programs.
Despite all the advancements in this field, there remain significant gaps in knowledge and barriers to scale that must be addressed in order to give every community the wherewithal to better manage its most complicated and costly health care users. With support from the Robert Wood Johnson Foundation and with input from leading experts across the country, CHCS recently developed a new framework for characterizing the biggest opportunities for advancing approaches to care for high-cost populations – including the following elements:
- Care model enhancements: improving the way we provide care to patients with complex needs;
- Financing and accountability: aligning incentives with broadly-defined outcomes and increasing flexibility to invest in services that work;
- Data and analytics: effectively targeting limited resources, tailoring interventions, and assessing impacts;
- Workforce development: building the capacity of the existing workforce and integrating new types of providers;
- Governance and operations: promoting community development and operational excellence; and
- Policy and advocacy: addressing key policy barriers and developing a collective voice.
In the months ahead, CHCS will continue to work with others leading this movement of policymakers, plans, providers, and consumer organizations exploring opportunities for further investment in each of these areas. Driving these efforts is a sense of unbridled enthusiasm for the collective opportunity before all of us in this field: to massively improve how we care for people with really complicated and chaotic lives, and to more wisely and sustainably invest our limited public resources in doing so.