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Managing populations with complex morbidities


Researchers generally agree that intense, highly-coordinated care, with an emphasis on changing patient behavior is a key to improving outcomes and reducing costs for complex morbidities.

Patients with complex morbidities have long been known to be among the costliest segments of the U.S. healthcare population. The federal Agency for Healthcare Research and Quality (AHRQ) estimates that more than 25% of all Americans have at least two chronic physical or behavioral health problems. However, treatment for those with multiple chronic conditions (MCC) represents some 66% of the nation’s health care costs, according to the AHRQ.


Urban Institute study, conducted for the U.S. Centers for  Disease Control and Prevention (CDC) prior to implementation of the Affordable Care Act (ACA), found 47.2% of the nation’s uninsured population may have at least one serious health condition, with 19.8% having more than one (see Chart 1). The study also found 39.6% of the nation’s uninsured population has diabetes, hypertension or hypercholesterolemia, with 14.2% having more than one of those conditions (see Chart 2). Serious health conditions were found to be uncontrolled in up to 77% of the uninsured population, the study notes.

With up to 10 million people gaining healthcare coverage under the ACA through Marketplace plans, employer-sponsored insurance (ESI) and Medicaid expansion, health plans have reason to be concerned about  increases in costs for the care of complex chronic conditions in newly covered populations.

Researchers at Dartmouth and other institutions have widely attributed high costs for patients with complex conditions to care that is often uncoordinated, fragmented or unnecessary. Lack of timely diagnosis and patient non-compliance with care regimes are also widely recognized as significant contributing factors.

Researchers generally agree that intense, highly-coordinated care, with an emphasis on changing patient behavior to encourage compliance, will be key to improving outcomes and reducing costs for complex morbidities.

With that in mind, at least four care management organizations around the nation now offer specialized care management programs to help insurers address complex chronic conditions. Most offer advanced analytics to identify  patients with, or at risk for, complex morbidities, as well as case management, disease management, and utilization review. At least two also offer specialized intervention services to modify patient behavior that could adversely affect cost and outcomes.

NEXT: PopHealthCare



The Tempe, Arizona-based healthcare services organization PopHealthCare offers integrated solutions in risk adjustment, high risk population care, and quality improvement, facilitated by the company’s proprietary tools and technology.

“Our high-risk population care programs use a combination of old fashioned house calls, modern day analytics, cutting edge technology, and best practice guidelines,” explained Mike Tudeen, CEO of PopHealthCare. “Improving lives one individual at a time, improving outcomes one population at a time, and contributing to the overall improvement of our healthcare system are the cornerstones of PopHealthCare.”

CareSight, PopHealthCare’s comprehensive high-risk population care program, uses advanced analytics to predict members most at risk for avoidable hospitalizations and complications due to their conditions and delivers face-to-face, in-home treatment and care support that lowers costs while delivering better health outcomes, improved star ratings and greater risk score accuracy. The program works with health plan physician networks to supplement in-office care with longitudinal care delivery, including house-call visits to provide care in the homes of high risk members with chronic illness or those who may have difficulty traveling to primary care regularly.

“While other analytics services may provide lists of patients who need care or lists of services that should be provided to those patients, those results may leave the health plan saying ‘I don’t have the resources to provide that care.’ PopHealthCare provides end-to-end solutions for high-risk population care, including analytics and the delivery of care,” Tudeen said.

CareSight provides a comprehensive system of care with a mobile team of clinicians led by a physician, nurse practitioner, or registered nurse (RN), according to Tudeen. Care is provided through in-home visits supplemented by telephonic outreach, 24-hour access, and other critical services such as improving medication adherence and integrating physical and behavioral interventions.

PopHealthCare’s mobile clinical team uses field-based diagnostic tools and assessments used to document care and quality guideline compliance for diagnosed conditions, and proactively evaluates patients with comorbid risk factors for undiagnosed chronic conditions. The team then coordinates with client network care teams to ensure seamless quality of care and proper documentation.

Tudeen emphasizes the service is available “24/7”, an important factor in improving patient compliance and avoiding unnecessary emergency room visits.  

“When a patient with a complex condition calls after hours, they don’t get an answering service, they speak directly with a clinician who is ready to help provide care, over the phone or in person.  The concept of ‘taking care to the member versus taking the member to care’ lowers costs and ultimately delivers better health outcomes for the member,” Tudeen said. “In addition to improving quality of care and improving member satisfaction, CareSight quickly decreases the number of avoidable acute admissions by 30% to 60% .”

The PopHealthCare approach is working. With over a decade in business, PopHealthCare has more than 30 health plan clients with members in 49 states and Puerto Rico. Their clients include commercial health plans/health insurance exchanges, Medicare Advantage plans, Managed Medicaid plans, dual eligible/dual integrated plans and MLTC plans.

NEXT: Health Integrated


Health Integrated

Patients with chronic health conditions commonly have underlying psychosocial problems that hinder care and adversely affect outcomes, notes Sam Toney, MD, the executive vice president and chief medical officer of Tampa-based Health Integrated, Inc.

Health Integrated - through its flagship Synergy Targeted Population Management service - offers a chronic care management program that includes both medical and behavioral  management for patients, including intensive intervention for those deemed at high risk for contributing psychosocial disorders. Up to 40% of patients with chronic physical conditions also suffer from psychosocial  disorders that could affect outcomes, according to a 2008 Milliman Research Report.

However, Toney believes Health Integrated is the only health care management organization offering a comprehensive analytics and interventional program to coordinate medical and behavior care management for chronic disease patients at this time.

Like many healthcare management organizations, Health Integrated offers utilization review, case management and disease management. Like others, the firm uses sophisticated software systems to stratify patients according to risk for various chronic conditions. However, Health Integrated also classifies patients according to risk for related behavioral disorders.

In cases of high risk for chronic disease with underlying psychosocial problems, patients are assigned a licensed psychotherapist who provides an intensive intervention program, with a typical duration of  nine months. The interventions include  regularly scheduled telephone counseling sessions, generally 30 or 45 minutes in length, as well as print and online resources.

The company also offers a special needs plan (SNP) care model to help ensure patients receive the necessary medical and behavioral care.

Reaction to the Synergy program among patients so far has been favorable with satisfaction ratings generally in the 90% to 95% range, according to Toney. Moreover, data indicates the Health Integrated Synergy program is effective in improving outcomes and thereby reducing costs, Toney says.

Implementation of the Synergy system by the Community Health Plan of Washington contributed to an eight percentage point reduction in the plan’s medical expense ratio (MER) last year. Community Health Plan provides medical coverage for 20,000 Medicare Advantage and Medicare Dual Eligible SNP enrollees in the Evergreen state.

The plan also reported marked improvements in key clinical utilization measures among chronic disease patients, including a:

  • 15% increase in office/home visits

  • 54% increase in physical exams

  • 7% reduction in overall inpatient utilization with declines of 19% in surgical utilization

  • 9% reduction in outpatient utilization

  • 14% reduction in radiology in all settings

Based on those results, Community Health Plan is expanding use of the full suite of integrated services  to the 285,000 members in its Medicaid program. Researchers at Portland University have compiled a formal study on the results of Synergy implementation, which demonstrates higher levels of improvement in HEDIS scores over a comparison group.

Toney first came up with the idea of coordinating medical and behavioral care for chronic disease patients while completing his psychiatric residency program  at the University of South Florida. He has published an article in the Journal of Managed Care Pharmacy, related to the efficacy of early efforts of Synergy program. The publication revealed not only improved treatment outcomes for psychosocial conditions, with more appropriate utilization of resources (drugs) and reduced overall costs, but similarly improved outcomes for physical conditions in those patients, with similar utilization and cost improvements.

With both commercial and public plans facing new pressure to control costs for chronic disease patients, coordinated medical and behavioral care management may be an idea whose time has come, Toney says.

Complex morbidities with high risk underlying psychosocial drivers represent 5% to 7% of commercial insurance plan members, 7% to 12% of the Medicare population, and 9% to 15% of Medicaid plan enrollees, but account 30% to 40% of care costs across those insurance programs, Toney says.

NEXT: A growing opportunity


A growing opportunity

The Urban Institute report suggests that newly covered populations may actually be somewhat less prone to complex chronic conditions than previously thought.

Compared to Medicaid enrollees, uninsured adults were found to be less likely to be in fair or poor health, to have chronic conditions and functional limitations, and to exhibit certain health risk factors such as obesity or lack of exercise, the institute found.  

However, one in three are obese or have conditions such diabetes, hypertension, or hypercholesterolemia, according to the institute’s report. They are also less likely than the Medicaid population to know about those conditions or have them controlled.

“Even as potential new Medicaid enrollees are less impaired on average than current enrollees, they still have relatively high risk factors and prevalence of chronic conditions,” the Urban Institute concludes.

Toney agrees incidences of complex chronic conditions among the newly insured may not be quite as high a previously anticipated. However, pent-up demand among newly insured populations will still prompt a spike in care for complex chronic conditions over the short run, both Toney and the Urban Institute predict.

And while that demand for acute care may eventually level off, the demand for ongoing management of complex chronic conditions is likely to grow steadily over the long run, both Toney and Tudeen agree.  

Bob Pieper is a freelance healthcare writer based in St. Louis.


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