The United States spends 250 percent more than any other developed country on health care services, yet we are ranked below 16 other countries in overall life expectancy. A less frequently discussed statistic, however, is the degree to which the U.S. under-invests in social services: for every dollar spent on health care, only 50 cents is invested in social services. In comparison, other developed countries spend roughly $2 on social services for every dollar spent on health care. The U.S. is 10th among developed countries in its combined investment in health care and social services.
This imbalance has ramifications for the nation’s Medicaid program, where just five percent of beneficiaries with complex health and social problems drive more than 50 percent of all program costs. Many individuals in this high-cost group have chronic complex medical, behavioral health, and/or supportive service needs, and in the absence of coordinated intervention, they tend to be frequent visitors to emergency rooms and have high rates of avoidable hospital admissions.
Ironically, the health care system bears the costs of under-investing in social services, yet on its own, is ill-equipped to address many of the root causes of acute health issues such as poverty, homelessness, trauma, lack of accessible and affordable transportation, and social isolation. Effectively serving these so-called “super-utilizers” will be one of the keys to reining in the nation’s health care costs, but doing so will require an approach that may ask the health care system to reach beyond its traditional boundaries into social services.
Designing Care Coordination Programs
Across the country, a growing number of innovators in the health care sector are designing care coordination programs to better serve low-income, high-need populations and begin to address the relevant social issues. They are doing so to respond to patients who regularly come into their facilities — like Michelle, a 30-year-old woman in Portland, Oregon.
Michelle was sexually and physically abused as a child by her father, joined a gang as a teen because it gave her a sense of belonging, and began drinking heavily to dull her anxiety and depression. Today, Michelle has difficulty navigating the health care system because she is easily overwhelmed by large numbers of people and is mistrustful of male providers.
Or like Sam, who at 50 carries diagnoses of Type II diabetes, hepatitis C, hypertension, congestive heart failure, renal insufficiency, asthma, morbid obesity, and depression. He has been clean for three years from an IV drug habit, but is homeless and has no friends or family to help him manage his care.
The challenge of effectively addressing the care needs of patients like Sam and Michelle has gained increasing attention over the past several years, in large part thanks to an array of innovative opportunities to improve care and curb costs introduced through the Affordable Care Act (ACA).
As highlighted in a 2013 bulletin from the Centers for Medicare and Medicaid Services (CMS), Medicaid programs now have greater opportunity to support (i.e., pay for) an array of approaches, including health homes, accountable care organizations, and other innovative models, that help connect high-need populations to recommended services and ensure appropriate follow-up treatment. These models, as well as others that CMS’ newly-created Center for Medicare and Medicaid Innovation is investing in, address the reality that many high-cost patients cannot be treated effectively in brief office visits.
Additional Policies Needed
While these emerging efforts are to be applauded, additional policies are required to fully and sustainably address the needs of this population. Specifically, efforts to improve the quality of care and reduce the costs of super-utilizers must:
Recognize that much of what impacts health outcomes occurs outside of the health care system. It is impossible to separate the health care needs of individuals like Sam and Michelle from their social circumstances, or even to effectively treat their physical and behavioral health conditions without concurrently — and in many cases initially — addressing their social needs. Effective interventions must rely on access to non-health care services such as supportive housing, vocational training and transportation, among others.
An innovative example of health care and social service collaboration is the Center for Health Care Services (CHCS) in San Antonio, Texas. Recognizing that a significant number of individuals in San Antonio’s jails were entering the system due to untreated mental health or substance use issues, the organization cultivated a strong relationship with local law enforcement and created a jail diversion program that is lauded as a national model.
Rather than incarcerating individuals who have been picked up for issues related to untreated mental health and substance use, officers may bring these individuals to CHCS facilities to receive detox services and psychiatric treatment, and to get connected to medical, housing and social support services. These efforts have helped save the community an estimated $50 million dollars over the last five years through reduced recidivism and decreased emergency room utilization.
Develop payment structures that encourage cross-sector collaboration and partnerships. As health care payment models evolve to promote greater accountability for providers to deliver better outcomes and lower costs, non-health care services like those mentioned above are essential tools. Thus, the next phase in the evolution of accountable care models should include accountability for outcomes beyond the health care sphere (such as housing status, incarceration, and access to benefits) and should provide more flexibility to align or integrate financing across traditional silos.
This vision, recently referred to as a “Totally Accountable Care Organization,” requires the development of new coalitions within local communities and among partners that share responsibility for serving the underserved, including hospitals, clinics, housing providers, and jails. It also requires the support of policymakers at local, state, and federal levels to recognize this interplay across systems and promote opportunities for shared costs, savings, and accountability.
In Hennepin County, Minnesota, an innovative county-operated care coordination program known as Hennepin Health is bringing together multiple partners, including a local public hospital system, a federally qualified health center, the county’s department of human services and public health, and the county-run Medicaid health plan. This unique structure fully integrates medical, behavioral health and social services, offering shared financial incentives for collaboration.
This “joint accountability” model has allowed upfront investments to be made in cost-effective, sensible solutions that benefit all parties, such as the creation of a sobering center designed to keep individuals with addiction from cycling in and out of jails and emergency departments.
CHCS’ and Hennepin Health’s approaches offer a glimpse of how two health care innovators are supporting investments in social services to better care for Medicaid’s highest-need patients. The reforms enabled by the ACA and the pursuit of Medicaid expansion in many states have created a prime opportunity to address the key role of social determinants on health outcomes and health care utilization – particularly for individuals with complex needs.
There is no magic bullet for solving all the challenges of the U.S. health care system, but broadening the context within which we provide care for super-utilizers can help to control cost growth across multiple public programs and improve the health and lives of some of our society’s most vulnerable members.