As 2020 Nears, Addressing Needs Beyond Clinic Walls Rises on the Healthcare Radar

So much of healthcare happens beyond the walls of the clinic; health systems taking on risk—or just trying to do better for their patients—have little choice but to think about the social and behavioral problems that translate into higher rates of diabetes, obesity, or dementia.

These 3 costly conditions that already drive public healthcare spending—diabetes alone accounts for $1 of every $3 spent in Medicare—are projected to drive more as the population ages.

Different thinking about the “social determinants of health” is changing the role of health systems, according the panel in the Healthcare 2020 Series, a forward-thinking discussion that concluded the spring meeting of the ACO & Emerging Healthcare Delivery Coalition^®, which took place May 4-5, 2017, in Scottsdale, Arizona. The coalition is an initiative of The American Journal of Managed Care^®.

Moderated by Clifford Goodman, PhD, of The Lewin Group, the discussion featured Michael Griffin, MS, CEO of the Daughters of Charity Services of New Orleans; Jonathan Hirsch, MSci, founder and president of the precision medicine company Syapse; and Sachin Jain, MD, MBA, FACP, CEO of CareMore, a subsidiary of Anthem that delivers integrated care to Medicare and Medicaid patients.

Griffin started by explaining the health, educational, and economic conditions for his patients post-Katrina: the city’s devastation provided a once-in-a-century opportunity to remake the healthcare system, with a $100 million grant to create a system of primary healthcare centers to replace Charity Hospital, which had served New Orleans’ poor for generations. Electronic paper records replaced the paper files destroyed in the storm.

What’s much harder to replace, however, is intergenerational poverty, a culture that values living hard and eating well, and health and financial illiteracy that would make managing a health savings account (HSA) problematic for many.

In the past year, Griffin said, the launch of Medicaid exchange has been a game changer—enrollment statewide is already at 432,000, well ahead of the projected 375,000 for the first year. But Griffin said he’s struggling to replace the value-based payment systems introduced after Katrina under the grant, as he works one by one with Louisiana’s 5 managed care organizations (MCOs) to create per member, per month payment models. (He’s succeeded with 2 MCOs.)

There’s good news, however. “We’ve seen an increase in utilization of preventive services, focused through a private system managed for the public benefit,” Griffin said. By historic standards, this a revolutionary for Louisiana; for decades the poor received all their primary and acute care in a hospital, or “cattle call” setting, as Griffin put it, and these habits are hard to break. The use of electronic health recor and modern communications means Daughters of Charity can find out in real time when one of its patients visits the emergency department for a non-emergency and try to direct them to a clinic instead.

Similarly, Jain said CareMore uses neighborhood-based centers that feature specialized programs in diabetes, innovative solutions like managing chronic disease in the dental setting, and a new program it is launching this week to address loneliness in seniors, which is a leading contributor to poor outcomes. CareMore uses tools like senior-focused gyms and improved transportation.

“Because we are fully at risk,” he said, it costs less to offer these services on an outpatient basis than to admit someone on an inpatient basis.

“In the event they are admitted, we view most hospitalizations as a failure of the healthcare system,” Jain said.

Syapse, Hirsch said, helps health systems looking to take on more risk by speeding up the process that process that doctors would do naturally over years: make decisions based on what they’ve learned from seeing patients with similar cases. Only in this case, the data from a new patient are fed into a system that give the physician a look at patients with similar characteristics, and how they fared based on treatment choices.

“Physicians are pattern recognizers,” Hirsch said. “The issue here is, we’re reaching a scale and complexity of data they could not do on their own.”

At first, physicians have doubts but they warm to it as they see the power. In cancer care, the model is moving from treating cancer based on tumor location to treating a “molecular fingerprint."

“It scares people. It’s very disruptive,” he said. “The second thing that’s disruptive is that they think the costs are exploding, but they are just shifting.” Instead of resources going into expensive therapies that may or may not work, they are put in on the front end into better diagnostics and understanding of the disease.

All 3 panelists continued a theme of the day: patient preferences must be a part of the conversation from the start of care, and that care must address those things that Jain said, “might not be in the CPT codes.”

Jain and Hirsch agreed that after a cancer diagnosis, no treatment should begin without a discussion of patient goals and desires. Jain described a patient with a new diagnosis who had a long-planned visit to several East Coast baseball parks, and the patient was encouraged to go and start treatment after he returned. “Those visits to the ballparks were extremely meaningful to him,” Jain said.

Griffin said Daughters of Charity, the providers have created teams to focus on diabetes care, addiction treatment, and to integrate behavioral healthcare into visits. Griffin said high tech cannot work without the “high touch.” Daughters of Charity even brings in attorneys to help patients deal with housing problems or domestic violence issues, he said.

Jain said this is the “paradigm shift” in healthcare. “You don’t patients if they’re lonely if you can’t solve their loneliness. You don’t ask about domestic violence if you can’t do something about it.”

Goodman concluded with 2 questions. First, since 2020 is rapidly approaching, he asked each panelist to comment on what is ahead for 2025. Hirsch said for his company, that was nearly impossible. “We are trying to figure out how to create some sort of risk-based ACO-like model that will cover cancer care, and allow for some of the shifts we’re talking about to actually happen.”

Griffin said besides doing more to address the social determinants of health, more must be done to support workforce development of primary care providers. And Jain said it was time for “authentic conversations” about the fact that for the healthcare revolution to succeed, a “win-win” for all stakeholders isn’t possible. “We need to talk about what we need more of, and what we need less of.”

Then, Goodman asked the group to comment on what the American Health Care Act, passed the day prior by the US House of Representatives, would mean in their work.

"Access and coverage is the goal from my standpoint … if it falls short, then I’m not very optimistic,” Griffin said. Jain added, “We need to focus on the high costs of high-need complex patients. That’s about as nonpartisan an issue as there is.”