You’ve heard it before: 5 percent of patients account for 50 percent of healthcare spending in the United States.
In traditional Medicare, 93 percent of total spending is on patients who fit the same profile: They have more than one chronic condition, including substance-use and mental-health disorders. The U.S. healthcare system is not designed to provide optimal care to these patients. The fee-for-service system does little to facilitate the coordination among providers, the provision of social services, or the support between office visits that they need.
Focusing on the 5 Percent
Longtime readers of Leadership may remember a 2012 article highlighting an initiative led by Jeffrey Brenner, MD, who then was the CEO of the Camden Coalition of Healthcare Providers.1 Brenner developed an approach to working with “superusers”—in this case, the 1 percent who accounted for 30 percent of utilization—in Camden, N.J. He used insurance data to identify these patients, many of whom had addictions and mental illness that were exacerbated by poverty. Brenner found that connecting patients to housing, employment, transportation, and primary care significantly reduced their hospital and emergency department utilization.
Brenner’s approach garnered attention throughout the industry. The Camden Coalition expanded in 2016, creating the National Center for Complex Health and Social Needs with $8.7 million in foundation funding. In January, UnitedHealthcare launched a $15 million, three-year strategic partnership with the coalition to develop new models of care for patients with complex health, behavioral, and social needs. UnitedHealthcare also recruited Brenner to head up a new nationwide program based on the ideas he pioneered.
Striving for Scale
This partnership is a potential solution to what Brenner sees as a looming challenge. “I think we have a massive scaling problem,” he told the Philadelphia Inquirer in January, referring not only to the Camden initiative but also to other pilot programs across the country.2 “How do we take all those pilots and dramatically scale them? How do we take the learning that’s cropping all over the country and make them more than interesting pilot projects?”
I couldn’t have articulated the challenge better myself. As an industry, we are in the midst of what is turning out to be a long period of experimentation. We are at the point where one of our most pressing needs is to assess which experiments are working and then to leverage the successful experiments and scale them up. The Camden Coalition is a prime example—a collaboration between a provider group that designed and executed a successful experiment and a health plan that invested in an experiment targeting a key driver of unnecessary healthcare spending, not just a single care episode.
Other ongoing and proposed experiments similarly are designed to improve the care of patients with chronic conditions. For example, a private-sector proposal to bundle payment for a technology-enabled approach to chronic condition management involves frequent, personalized text messages—a modality that provides effective support to people living with conditions like diabetes, for whom daily choices have significant effects on their long-term health risks.
A more established example is the Centers for Medicare & Medicaid Services’ Comprehensive Primary Care Plus program, an advanced primary care medical home (PCMH) model that was launched in January and supports nearly 3,000 primary care practices. Additionally, the not-for-profit Patient-Centered Primary Care Collaborative is tracking nearly 500 public- and private-sector PCMH initiatives throughout the country.
Collaboration Is Imperative
Most care model experiments targeted at chronic conditions have one thing in common: They are not hospital-centric. Chronic conditions are managed primarily in physician offices and in patients’ homes, at least before complications develop.
That’s why collaboration among hospitals, physicians, and health plans is essential if we are to improve the care of people living with chronic conditions. Collaborative leadership is needed not only to improve lives but also to keep healthcare costs from spiraling upward in the years ahead.
Joseph J. Fifer, FHFMA, CPA, is president and CEO, HFMA. Follow Joe Fifer on Twitter @HFMAfifer.
1. “Addressing the 1 Percent,”Leadership, Nov. 1, 2012.
2. Von Bergen, J.M., “UnitedHealthcare gives Camden health-care coalition $15 million, takes Brenner,” philly.com, Jan. 31, 2017.