Five ways to control Medicaid super user costs

The most recent report on Medicaid from the U.S. Government Accountability Office (GAO) reveals a very small share of enrollees, just 5%, are eating up nearly half of total costs.

Read: Health homes provide super utilizer support

Medicaid’s continued expansion in the U.S. under the Affordable Care Act raises the question: How do we reverse the trend of “super users” and reduce costs for this small, unique pool of members?

The health complexities of the “super user” population necessitate broadening one’s perspective on the drivers behind overutilization, innovation, and specialized, unique care management. For example, while much weight has been given to the impact economic and situational factors have on healthcare spending, psychological drivers are often large factors that go unrecognized and unaddressed, and are siloed from health management.  

Here are five ways to address the complex super user population.

Next: Bigger, Better Data

1. Bigger, Better Data

Reaching super users with the big picture objective of mitigating utilization is most effectively accomplished through access to accurate, timely and comprehensive data. Physician and hospital claims data, however, are only a single, small piece of the puzzle.

Data are varied and diverse. While payors are accustomed to administrative data through claims, they must begin to dig deeper into data sources, including member pharmacy and laboratory data, electronic health records, and any additional available consumer data, to gain a more accurate picture of the landscape. These data facilitate more precise intervention.

Next: Improved Identification of Mental Health Conditions

2. Improved Identification of Mental Health Conditions

Less than 15% of Medicaid enrollees are affected by mental health conditions, according to the GAO report. That percentage may be higher. In order to be counted in that percentage, an individual’s condition must be accurately identified, reported and documented.

Despite a heightened awareness during the past several decades and perceived general acceptance of such mental health conditions as depression and post-traumatic stress disorder, these conditions and others remain stigmatized. Providers are sensitive to the stigma and may underreport. Additionally, drivers impacting adherence to treatment plans, including personality and maladaptive behaviors, do not fit neatly into the established medical coding system.

Based on my 12 years of managing these populations, I believe there are many gaps and underreporting, a lack of access and a failure to follow through on recommended treatment with behavioral health specialists.

In other instances, there are patients who have psychological issues who are not being seen at all by behavioral health providers, and will never be identified or diagnosed. Additionally, there are patients with very burdensome physical health issues, but the psychosocial factors complicating their conditions are overlooked or undiagnosed. It is easy to see why patients slip through the cracks.

Next: Early Intervention

3. Early Intervention

Data, even if minimally available, play a key role in early intervention. In catering to patients with overwhelmingly burdensome health issues, actionable data allow us to identify potential gaps in care and hone in on the right interventions, for the right individuals, at the right time.

Member intervention should be approached from a holistic perspective. It should address the root causes of overutilization and physical issues complicated by psychosocial factors. In combination with actionable big data, this approach plays an integral role in successful precision-empowered care management.

Next: Care Coordination

4. Care Coordination

The availability of accurate, comprehensive data allow us to begin bridging the gap in care between patients with physical ailments and those bio-psychosocial issues that are harder to recognize and address.

Too often, patients are pigeonholed at one end of the healthcare spectrum, and their physical and mental health issues may be managed, but they are being managed separately. The complex layers between the ends of this spectrum must be appreciated. Innovation is required in managing psychosocial barriers. They cannot be siloed from health outcomes or fall solely on behavioral health specialists. Timely, meaningful and effective management of these complex patients “takes a village.”

The correlation between Medicaid members with comorbidities drastically higher per-member-per-month (PMPM) spending when compared to PMPM spending across enrollees without any reported physical or mental conditions underscores the urgent need for better coordination across the care continuum.

Next: Recognition and Awareness

5. Recognition and Awareness

A general lack of education about this population has led to a broad categorization of what the super user looks like.

It is only when we recognize that the issue is not black and white, and learn the motivational and driving factors behind a patient’s actions (or lack thereof) in caring for their health, that we can begin to provide them with proper care.

Sam D. Toney, MD is chief medical officer and EVP of clinical integrity for Health Integrated. He provides primary clinical, program and criteria oversight for Health Integrated and brings more than 25 years of expertise in designing and implementing successful specialized behavioral health disease and case management programs across the country