The health system’s care management organization is developing strategies to keep patients who are affected by substance abuse, mental illness, and unstable housing healthier and out of the hospital.
In this interview, Stephen Rosenthal, senior vice president of population health management at New York’s Montefiore Medical Center and president and COO of CMO, Montefiore Care Management, discusses population management strategies for high-cost patients.
On determining the drivers of healthcare costs. In an in-house analysis of 4,000 high-risk patients with Medicare, Medicaid, and commercial coverage, Montefiore found that those with a history of substance abuse had 89 percent higher costs than the average patient.
“Many of our patients with a long history of substance abuse also develop HIV or hepatitis C, or both,” he says. These diseases can be medically debilitating and require costly pharmaceutical treatment. The CDC estimates the lifetime treatment cost of an HIV infection is more than $379,000. Meanwhile, the cost of some hepatitis C therapies may exceed $80,000. These therapies cost the government $18 billion in 2014 and 2015 combined, according to the Health Affairs blog.
Many patients are covered by health and recovery plans (HARPs), New York State’s managed care plans for adults with significant behavioral health issues. Through these plans, which are intended to improve beneficiaries’ access to vital care, the state provides an enhanced premium, recognizing that such individuals are more costly to manage.
Among Montefiore’s programs and services are 22 primary care sites that serve large populations with complex clinical and psychosocial needs. In addition, Montefiore has five methadone maintenance clinics that care for 4,000 people each year. HIV services are provided by primary care physicians and physician assistants who have ongoing training in HIV treatment and are HIV specialists, as defined by the New York State AIDS Institute.
In this model of “reverse integration,” a provider might treat patients for hepatitis C and HIV, review their recent lab tests, and even sign off on disability or welfare applications. “If we can be proactive at the point of care, when patients are there for their methadone maintenance, we can get more accomplished and hopefully keep them out of harm’s way,” Rosenthal says.
The clinics also provide directly observed therapy for patients who have difficulty taking their daily medications, which is especially important in HIV care. When patients come in for their methadone, they also receive any other medications, as well as take-home doses for days when they are not in the clinic.
On managing patients with mental health issues. Montefiore’s in-house analysis also found that patients with a mental health diagnosis and a medical condition, such as congestive heart failure or hypertension, had healthcare costs that were 38 percent higher than average. “These are patients whose medical conditions will not be controlled and who will not be able to comply with medication adherence as long as their behavioral health issues are not effectively treated,” he says.
Rosenthal’s team has worked with the leadership of Montefiore’s network of primary care clinics on a model of care that provides patients with greater access to behavioral health services. As a result of this collaboration, Montefiore embeds a psychologist or a psychiatric social worker who can contact a psychiatrist in all of its primary care sites. A model that includes patient educators functioning as care managers in the clinic increases the effectiveness of the behavioral health care provided, Rosenthal says.
Patients who are identified with behavioral health issues, either through screening or in discussion with their physician, are introduced to these behavioral health specialists, who can provide therapy or more intensive interventions. “This way, there can be a hand off at the point of care when a patient presents with mental health issues,” Rosenthal says. Preliminary data from almost 5,000 patients found this approach reduced the severity of depression symptoms by nearly half.
The health system, which is the lead of a New York State Medicaid Health Home, is working with a number of state and community-based behavioral healthcare programs to improve access. Montefiore is also testing smartphone applications to facilitate contacts between patients and care managers. “By giving patients some choices, we can improve compliance with care plans, and we have seen a real benefit in lowering our overall medical cost,” Rosenthal says.
Montefiore was recently awarded two grants for a pilot program that would expand their efforts beyond Montefiore and integrate behavioral health services into smaller primary care practices across New York State. Through the grants, as many as 25,000 patients will be screened for depression.
On managing patients with unstable housing. In Montefiore’s analysis, patients with unstable housing environments had 16-20 percent higher healthcare costs, compared with average patient costs. “These individuals tend to find themselves in emergency rooms fairly frequently, and if they get admitted, that adds to healthcare costs substantially,” he says. In 2016, Montefiore’s emergency department successfully made connections for housing services for 122 patients with immediate needs.
Montefiore’s care management organization mines their electronic health record (EHR) data to determine which patients could benefit from its services. When unstable housing environments are identified during assessments, Montefiore works with organizations like BronxWorks, which provides food and shelter to Bronx residents.
In addition, Montefiore employs a team of navigators and social workers who are alerted when homeless patients present to the EDs or have been admitted several times over the past few months. “Our team will reach out to the individual in the emergency room to try to determine the best point of care. Moving them to a safe housing environment might make more sense than admitting them to the hospital,” he says. Thanks to the team’s efforts, ED visits resulting in inpatient admissions of patients with unstable housing or high utilization profiles dropped from 25 percent in 2009 to 13 percent in 2015.
On overcoming the challenges associated with these strategies. “When you intervene in these social-related issues, you help support people in many aspects of life,” Rosenthal says. “Most healthcare organizations are not prepared for that. These are problems that have been mostly taken care of by social service organizations in the community. But we recognize that if we want to moderate and manage the total cost of care, we have to help address some of the life constraints that all of us face in different degrees, but often people with limited resources face in a significant way.”
Advice for other organizations. “If healthcare organizations stayed in a fee-for-service environment, costs would continue to escalate, and the industry would continue to ignore what happens after the transaction with the patient,” Rosenthal says.
“But when organizations are thinking about managing a population, especially those with behavioral health issues, it is imperative to address the social determinants and think about these challenges along the continuum if they are to bring value to the community they serve. That requires making some investments and centralizing resources so they can have some economies of scale to help manage the volume of patients.”
Interviewed for this article:
Stephen Rosenthal is senior vice president of population health management, Montefiore, and president and COO, CMO, Montefiore Care Management, Bronx, N.Y.