Meet Cindy B. Cindy is a Medicaid patient with a diagnosis of diabetes with complications, and an anxiety disorder. She also suffers from unstable housing, and lives with her mother who has a substance abuse disorder and other health conditions. Cindy is fortunate to have a community health center care team that includes providers with experience in physical and mental health services. There are millions of people like Cindy across the country, and not all are fortunate enough to receive the level of integrated care that Cindy does.
The state of integrated care
Despite outspending other comparably developed countries on medical services, including high technology services and pharmaceuticals, we continue to see poorer outcomes, higher mortality rates and a greater prevalence of illness in the U.S. Our fragmented approach to healthcare and focus on expenditures within the four walls of the hospital and specialist’s office is at the root of poor health outcomes, and has led to higher costs and poor patient experience. To solve this, we must focus first on connecting the patient and care providers across the continuum, and look beyond traditional medical services to address such issues as lack of adequate housing, transportation, food and other conditions impacted by socioeconomic factors. Cindy’s health plan understands this, and works to address her unique needs, but not all health plans integrate care for members at this level. Unless we reduce the siloed approach to service delivery and broaden our view of what influences health, we will never see meaningful change in healthcare costs and outcomes.
One of the great benefits of effective managed care is its potential to facilitate integration of services across a broad spectrum based upon the individual patient’s needs. Such services include traditional medical, pharmacy, and behavioral health services as well as social services; all are necessary to support the patient, particularly one with complex needs like Cindy. Despite the great potential of managed care to reduce the fragmentation of the health delivery systems, traditional managed care plans all too often miss this opportunity.
The most innovative Medicaid managed care organizations and Special Needs Medicare Advantage plans have generally led the way in executing on the integrated care model. Community Health Plan of Washington (CHPW), a Medicaid and Medicare health plan that was founded and is governed by a state-wide network of Federally Qualified Community Health Centers, uses the integrated care model through its investments in its Community Health Center partners who provide a patient-centered medical home for approximately three-quarters of CHPW’s members. While it is a natural fit for a health plan to approach care delivery from this whole-person model, other health plans, and ACOs, have the ability to support whole-person integrated care if they are willing to make the necessary investments.
A “whole person” approach to care
Cindy’s experience illustrates the value of whole person care. She benefits from a community health worker, paid for by her health plan, who helps her to obtain emergency housing resources, transportation and food stamps. The community health worker helped Cindy connect with community resources, including church groups, that have provided past support. A behavioral health specialist care coordinator works with Cindy’s team, and is familiar with her family. Her health plan shares information about Cindy’s past hospitalizations and emergency department visits with her care providers, and communicates her medication adherence through its pharmacists to Cindy’s CHC pharmacy. Finally, Cindy’s health plan identifies opportunities for further population health interventions and quality improvements for Cindy, and works with her primary care team to ensure that her diabetes is well-managed despite her anxiety disorder. This is a whole person approach to care.
Here are two ways to improve health by addressing whole person care.
1. Incentivize whole person care.
The whole person approach to care is most successful when there are aligned financial incentives. It requires appropriate information sharing and communication across the team, and is most effective when the member is engaged in their care plan. It often takes time for trusted relationships to develop, which requires an investment in both time and resources to facilitate an integrated approach. The costs are more than offset for a patient who would otherwise incur hospitalizations, specialty services, high-cost pharmaceuticals and procedures. Upfront investment in integrated, whole-person care improves outcomes, reduces costs and improves experience for both the patient and the providers.
In the Southwest region of Washington state, Medicaid contracted with CHPW and one other MCO to implement a fully-integrated managed care model that included mental health services for populations that had previously been carved out of Medicaid contracts. After one year of executing these services, there has been an independently verified reduction in the avoidable emergency department and hospitalization trends as well as improved quality measures. This evidence has supported the state’s decision to move forward with an integrated financing system for physical and mental health services across the state, which will significantly improve the ability of health plans to support the integrated care model.
2. Set the stage for care integration.
Medicaid and Medicare managed care plans have been leading the way in improving health with innovative models that support a whole person approach to care. By leveraging connections at the community level and supporting an integrated approach to care, CHPW has made significant strides toward achieving better outcomes, lower costs and improved member and provider experience.
The integrated model of care improves the health and well-being of individuals—like Cindy—and families; it strengthens whole communities, and it contributes to managing the cost of care. It is a model that works for CHPW’s members, and it offers a blueprint to solving our challenge of fragmented healthcare in the U.S.
Leanne Berge is chief executive officer of Community Health Plan of Washington (CHPW) and Community Health Network of Washington (CHNW).