Healthcare News & Insights

Managed care: High-cost patients have other needs not being met

Social determinants of health are interfering with the efficiency and cost savings of managed care, according to a government watchdog’s report. 

The Government Accountability Office (GAO) reports that just 5% of Medicaid beneficiaries use up half of the program’s overall spending.

Managed care’s goal is to coordinate care across differing providers and rein in high-cost beneficiaries. According to the Kaiser Family Foundation, more than two-thirds of all Medicaid clients get most or all of their care from a managed care organization.

What are the hurdles?

The 5% come from a diverse population with varying needs. They aren’t as easily taken care of by managed care agencies because they have one or more of these situations:

  • Homelessness
  • Food insecurity
  • Lack of transportation
  • Living in a rural area with lack of healthcare providers
  • Limited communication (relying on a cell phone with limited minutes), or
  • Poor living conditions that affect health.

“We know that medical care alone is not enough to make people healthy,” said Nancy Copperman, vice president of community health at Northwell Health, as quoted in FierceHealthcare. “Total health also requires healthy food, a safe place to live and the ability to get the care you need.”

Potential solutions

Some states included in the GAO study are trying to implement strategies to address that high-cost 5% of Medicaid recipients.

Nevada added payment incentives for managed care organizations if they performed well on certain measures like immunization rates. The GAO reported that the state later had problems measuring outcomes.

Indiana tried to curb overuse of healthcare services by high-cost beneficiaries who may be engaged in doctor or pharmacy shopping by locking them in to a single pharmacy, doctor or hospital.

Yet many managed care executives advocate that plans must address social determinants that factor into some clients using a large portion of the care funding.

In New York, Northwell Health and NowPow, a tech company based in Chicago, are working together to better identify patient’s most urgent non-medical needs.

For example, diabetics unable to get their condition under control may be experiencing food insecurity and not have access to enough fresh, healthy foods. A steady diet of processed foods with a higher percentage of sodium and artificial ingredients can prevent a diabetic from keeping their blood sugar in a healthy range.

A patient with asthma, as another example, may have recurring problems if they’re limited to poor-quality housing and have mold in their living space.

Transportation limitations can prevent clients from getting to their pharmacy or regular doctor appointments to manage their conditions, resulting in more ambulance trips to the emergency room than the average client.

To address these issues, Northwell and NowPow are using NowPow software that tracks diagnostic codes in electronic health records to recommend community organizations that can help with patients’ social needs.The NowPow software program takes into account a patient’s geographic location, eligibility for services, languages spoken and other factors.

According to Northwell, Medicare patients who received referrals from the software had fewer emergency department admissions than Medicare patients who didn’t.

Kaiser Permanente recently announced plans for a new care network to better connect its 12.3 million patients with the community services they need, such as food, housing or transportation. Named Thrive Local, it’s expected to be rolled out across the Kaiser Permanente system within three years.

In managing patient treatment, addressing the nonmedical, or social determinants, can both improve patient care and reduce long-term per-patient costs to Medicare.

Hospitals should be screening all patients on key social determinants of health during their hospital stay, per the Centers for Medicare & Medicaid Services, including access to food, housing, education, transportation and more. Doing so can help clinical staff put patients on the right road to recovery after leaving the hospital.

One effective screening tool to try is the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE), used successfully by hospitals and health centers across the country.

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