A new approach to care management for patients with comorbidities

November 14, 2014

Approximately half of all adults in the U.S. have one or more chronic health conditions, and 75% of health care costs are due to chronic illnesses. When psychosocial issues like depression, low income, or lack of social support are present, the impact on costs is even greater.

Approximately half of all adults in the U.S. - 117 million people - have one or more chronic health conditions, according to the CDC. Even more staggering is the fact that 75% of health care costs are due to chronic illnesses.1 When psychosocial issues (examples like depression, low income, or lack of social support) are present amongst individuals with chronic conditions, the impact on costs is even greater. Why?

The underlying psychosocial issues can have a significant impact on how an individual responds to treatment for their chronic conditions. Notably, 29% of adults with a medical condition also have mental disorders.2

Individuals on Medicaid and Medicare are particularly vulnerable as they routinely face social and economic stress in addition to psychological issues commonly experienced with a chronic condition. Oftentimes these issues are not diagnosed nor are they addressed in traditional care management models. Adverse results include when a patient is non-compliant which in turn leads to higher utilization of medical services such as emergency room visits, hospital admissions, and unnecessary procedures which drive up costs.

So how do we address psychological and social barriers? The healthcare system must change its way of viewing care management by not just addressing the medical needs of an individual but also the behavioral, environmental, and support system needs. This can be accomplished with a “precision care management” approach that pinpoints individuals most in need of therapeutic intervention.

An initial step of precision care management utilizes actionable big data sets such as demographics, claims data, and utilization history from which a health plan can target individuals with psychosocial risk patterns. This allows the plan to focus more on the individuals representing the highest risk for increased utilization which is the first critical step in the process.

The next phase involves engagement with the members and their healthcare ecosystem.  Individuals are invited to join a targeted intervention program that is customized to their needs and designed to educate and empower them to take control of their health. This is achieved through intensive one-on-one sessions with a personal clinician to address the root cause of the non-compliance.

Additionally, the physician, providers, and social support system are actively aligned to one clear plan of care. The individual may also require assistance with community resources such as transportation to get to doctor appointments. The end goal is to address each individual holistically, and to have the individual make changes over time in behavior to impact health status and reduce avoidable expenses. This impact multiplies across a health plan, reducing utilization and providing a positive impact to a plan’s medical loss ratio.

In the end, health plans must change their approach to now address both the chronic condition itself and the psychosocial issues at the individual level to truly make an impact. By identifying members most in need of therapeutic intervention, outcomes will improve for individuals with comorbidities and for the health plans serving them.

1.CDC, Chronic Diseases, The Power to Prevent, The Call to Control: At A Glance 2009, http://www.cdc.gov/chronicdisease/resources/publications/aag/pdf/chronic.pdf

2. Mental Disorders and Medical Comorbidity, Robert Wood Johnson Foundation, 2011, http://www.rwjf.org/content/dam/farm/legacy-parents/mental-disorders-and-medical-comorbidity

Sam D. Toney, M.D. is the Chief Medical Officer and EVP, Clinical Integrity for Health Integrated. He provides primary clinical, program and criteria oversight for Health Integrated and brings more than 20 years of expertise in designing and implementing successful specialized behavioral health disease and case management programs across the country. A board-certified psychiatrist, Sam founded Health Integrated in 1996 in response to the growing need for sophisticated care management systems that address both the medical and behavioral health issues affecting patient care. Sam is licensed to practice medicine in 25 states and is also board certified in utilization review and quality assurance.