How to connect with the sickest, neediest patients

Changes to the Medicaid program could disproportionately affect many of the neediest, sickest Americans, according to data from the Commonwealth Fund’s Survey of High Need Patients.

The nationwide survey of patients with complex medical needs, shows that nearly half of adults with Medicaid are aged 50 years or older and many have multiple chronic conditions, behavioral health problems, or physical limitations or disabilities.

Ryan

“The Medicaid population is not just prime working-age people; there are a lot of older people who are approaching Medicare eligibility age, but not quite there yet,” says Jamie Ryan, senior program associate, Delivery System Reform, The Commonwealth Fund.

“These findings are important to managed care executives because they paint a picture of a subset of Medicaid patients who are not often discussed,” adds Ryan. “It’s important to remember that the Medicaid population is fairly heterogeneous and includes both clinically and socially complex people of all ages. The financial and medical stability provided by Medicaid can be hugely helpful to this group of older, sicker adults.”

Furthermore, the survey found that nearly a quarter of adult Medicaid enrollees are eligible for Medicare as well, based on being aged 65 years or older.

“A lot of these older adults are sicker than average,” Ryan says. “They may have multiple major chronic conditions such as heart disease or kidney failure, or have functional limitations in their ability to perform daily tasks like meal preparation or bathing, or they may have a disability.”

Two-thirds of sicker older adults with Medicaid live in states that expanded Medicaid eligibility under the Affordable Care Act. This group would be adversely affected by state or federal decisions to roll back Medicaid expansion, according to Ryan.

Among sicker adults aged 50 to 64 years, those who do have Medicaid are less likely to forgo care due to costs. 

The survey also showed that while nearly all of the high-need patients surveyed have consistent access to healthcare-95%-they grapple to get coordinated medical, behavioral, and social services needed to stay healthy and avoid costly hospital visits. Specifically, they had limited access to: care coordinators, assistance in managing functional limitations, emotional counseling, and transportation services.

Smiley

A prerequisite for connecting high-need patients to care is resolving the information disconnect between care coordinators, medical and mental health providers, and payers, according to says Neil Smiley, CEO of Loopback Analytics.

“Siloed healthcare data hampers care coordinators’ ability to get the full picture of patient needs and history needed to fully inform a plan of care,” Smiley says.

Next: Here's what the experts say

Experts weigh in

The survey findings are not surprising and illustrate the complexities faced by managed care executives in balancing care and cost of high-need patients, especially when those patients have chronic medical conditions combined with unmet mental health needs, according to experts.

Rajan

“The healthcare management system, especially for patient populations dealing with complex comorbidities, is riddled with education and care coordination gaps,” says Arvind Rajan, CEO and co-founder of Cricket Health, which provides technology-enabled care in the home for patients with advanced stage chronic kidney disease (CKD) and end-stage renal disease (ESRD). “

These gaps often lead to narrow and expensive treatment options and delayed or incomplete plans of action, resulting in tremendous cost burdens for health systems and generally poor outcomes for patients,” Rajan says.

Hobson

High-need patients typically have multiple chronic conditions and delay accessing appropriate care, which in turn leads to a reliance on the emergency room where care is both expensive and not well tailored to meet their social and behavioral health needs, according to Chris Hobson, MD, chief medical officer, Orion Health. “These patients struggle to get the high-quality, coordinated care they require in the community where it’s most appropriate and most likely to be beneficial,” Hobson says.

Smiley shares a similar viewpoint. “Without careful alignment, spend associated with high-need patients may be wasted delivering one-size-fits-all interventions to a diverse cohort,” he says. “Active measurement and adjustment of interventions relative to their expected outcomes is critical for delivering right-fit care.”

A patient’s ability to cope and manage a disease, and then make and adhere to treatment decisions, first requires them to understand their condition, symptom and prognosis, Rajan says. “Unfortunately, in the confines of a doctor’s visit, information may be too sparse, or worse, delivered with such volume that it is impossible for any patient to properly digest,” he says.

Effective patient education requires more than the dense transmission of information during brief physician interactions, according to Rajan. “It needs to take into account where patients are in their lives, and should guide them toward decisions that take into account their values and goals for future,” he says. “These are often life-changing decisions, with implications not only for patients themselves but their loved ones.  It should be available on-demand, when it’s convenient for the patient, and provide the ability to engage with clinical professionals as well as peers and patient mentors. The good news for managed care executives is that such structured education and engagement programs do exist, and are showing strong results.

“Patients who are well-informed about their disease and the options available to treat or manage their condition are proactive stakeholders in the decision-making process,” Rajan says. 

Drouin

The findings also fit with the data that there is enormous variation in both the cost and the quality of care outside the hospital, according to Jean Drouin, MD, MBA- CEO and co-founder of Clarify Health Solutions.

“This is a natural byproduct of the fee-for-service reimbursement mechanisms that have dominated healthcare in the past hundred years,” Drouin says. “No one has been incentivized to act as the quarterback across a journey of care. As the burden of disease has increasingly shifted from acute events to chronic disease, payment models have not adapted in step. What managed care providers must do is embrace the same real-time coordination and logistics technology that enables FedEx and UPS to manage complex distribution chains-and to reward providers, payers should accelerate the roll-out of risk-sharing reimbursement arrangements such as episodes of care.”

Managed healthcare executives have a range of solutions at their disposal to address the situation, according to Hobson. “From an information technology perspective, it’s clearly important to identify and better understand the needs of these patients in as much detail as possible,” Hobson says. “In addition to identifying and understanding high-need patients, technology can help in other ways such as: Remote patient monitoring, care coordination technology including a shared patient care plan, medication reconciliation and care team management.”

These types of patients frequently have a wide range of care providers involved in their care, which increases the need for technology to assist in their care coordination, according to Hobson.  “A complete longitudinal care record that includes access to social and behavioral determinants of health is clearly advantageous information for every clinician that interacts with high-need patients,” he says. “Ready access to holistic data at the point of care enables providers to better identify and prioritize patients’ needs at a population and individual level; effectively coordinate and manage their care; and proactively drive improvements across the community through prevention and early intervention for quality health outcomes."