Improving Costs and Outcomes Across Complex and Vulnerable Populations

Coordinated care is an essential part of redefining the future of healthcare. A single integrated ecosystem means we can finally optimize healthcare decisions and be proactive rather than waiting for the patient to knock on the doctor’s door. Unfortunately, forward momentum is not that simple with the steady rise in healthcare costs impacting the success of technology. Perhaps these rising costs have also served as a catalyst for notable increases in the number of Medicare Advantage (MA) enrollees between 2004 and 2017—tripling from 5.3 million to 19 million. The Congressional Budget Office projects MA enrollees to reach 37% of the population by 2020 and 42% of the population by 2028.

The main causes for the boom are the advantages that MA plans offer the consumer, the plan provider, and the health system at large. Consequently, these trends will likely continue, and payers who work in the MA space will increasingly need resources for effectively managing these populations. It’s just 1 reason payers need innovative tools and forward-looking care management models that address the full spectrum of member needs. In other words, the right technology and processes are required to support proactive care for the most vulnerable populations while addressing the social determinants of health (SDOH) that are significant factors for today’s Medicaid and MA populations.

That’s partly why last year, MA plans began offering benefits to address issues of SDOH. In November 2018, HHS Secretary Alex Azar said the department would look to further align spending in traditional healthcare services with spending on services that relate to SDOH. The vision to address SDOH does not end with Medicaid and vulnerable populations, though, as Azar has also mentioned the importance of aligning these strategies with Medicare programs and providing MA plans the flexibility to address these issues with older patients, as well.

Integrating Care Management

There are many ways healthcare organizations can leverage innovative technology solutions to address care gaps in real time. For example, by aggregating and analyzing multi-dimensional member data, including clinical information, behavioral assessments, risk algorithms, and SDOH, the right platform can optimize interventions based on a 360-degree view of each member. Integrated care management recognizes the link between physical and behavioral health and incorporates the tools needed to address both. Advanced solutions equip care teams with actionable insights into clinical and behavioral risk factors, resulting in improved outcomes and lower costs.

Let’s look at just 1 subset of SDOH: transportation. A patient’s ability to get to and from appointments or pick up medications is vital to improving health outcomes. Yet, transportation represents a huge care gap in high-risk patients that payers must identify, acknowledge, address and overcome. There are some vendors today who offer a complicated, siloed process of layering patient information with transportation needs and then there are others. The most advanced solutions offer a transportation module as part of an integrated system that combines all the care gaps a patient may face. When clinicians can work with technology that enables scheduling recurring trips for patients without leaving their daily platform, they can increase access to often overlooked activities, like doctor’s office and pharmacy visits, driving population health improvements.

One managed health plan was able to forecast usage trends across months, time of day and geography to help its team optimize operations and predict transportation expenditures. For example, the company can determine which patients are frequent transportation users, which can alert care managers to book multiple provider appointments at once to reduce costs versus on separate days.

The Future of SDOH

The healthcare industry needs to take a deeper look at all factors that impact care and take greater strides toward treating the whole person. Consider that many patients suffer with at least 1 SDOH challenge, with a large percentage having moderate-to-high risk in at least 1 of the following categories: financial insecurity, social isolation, housing insecurity, addiction, transportation access, food insecurity, and health literacy. All are circumstances with a direct effect on mental and physical health for both individuals and the communities in which they live and work.

And yet the most exciting work in this field is yet to come. In the future, it will be possible to obtain characteristics of what type of members are utilizing transportation services, for instance, including who will use them the most and their specific needs and health histories. Being able to predict and identify seasonal changes (like an early January slow-down), reasons for rides (such as behavioral health) and geographical hotspots, will enable patients to get the care they need. If we can make transportation and other services addressing SDOH gaps more accessible, we can have a bigger impact on healthcare and help tackle some of the variables that cause care disparities across society today.