Patients with complex needs require a custom approach


AHIP 2017: Older adults with complex chronic conditions require payers to “look under the hood.”

Two-thirds of Americans age 40 years and older say the country isn’t ready to handle the rapid growth of the older adult population, according to the 2017 Long-Term trends poll, which was conducted by the Associated Press and the University of Chicago’s NORC Center for Public Affairs Research.

It’s with daily activities-such as cooking, bathing, and remembering to take prescribed medications-that older adults often need help and support, Gretchen Alkema, PhD, vice president of policy and communications at the SCAN Foundation, a public charity focused on transforming care for older adults in ways that preserve dignity and encourage independence, told Managed Healthcare Executive (MHE).

There were more than 77 million adults age 65 years and older in 2011, according to the U.S. Census. While that number is projected to drop to 60 million and decrease further by 2060 to only 2.4 million, the remaining baby boomers will be age 96 years and older.

In Alkema’s June 8 presentation at America's Health Insurance Plans (AHIP) Institute & Expo 2017 Institute & Expo, in Austin, Texas, she provided insight on caring for patients in this growing demographic. She introduced the audience to “The Playbook: Better Care for People with Complex Needs,” which provides a business case for serving these patients, outlines the most promising payment and policy models, in addition to providing a variety of other resources. During her session, she also talked about older adults and their complex care needs.

“One of the things that healthcare executives think a lot about is wanting to do the right thing for people in their health systems-particularly those on Medicare who have chronic health conditions. But we know that the vast majority-almost 90%-of Medicare beneficiaries have at least one chronic health condition.”

Since so many Medicare Advantage beneficiaries have multiple chronic conditions, it’s difficult for healthcare executives to target and help people those are high-cost and high-need, she said. What can make the difference is isolating those patients with daily living challenges, such as likelihood of falling, ability to drive a car, and whether they live alone or with a caregiver.

“Whether you have one, two, or three, four, five chronic conditions, the differential in cost when you look at those that have functional challenges and those that don’t, is stunning,” Alkema told MHE.

When a person has a functional impairment, it really can drive up their healthcare costs, which means healthcare executives should focus on this small population of patients. “It’s that small group of patients, whether it’s determining who’s the 5% who have the highest needs and highest costs or the 1% that has the highest needs and highest costs,” she said.

While much of this information isn’t available in clinical or claims data, many payers engaged in Medicare Advantage plans are already required to capture data from patients in the health risk assessment (HRA), added Alkema.

There isn’t a standard list of questions that needs to be an HRA. “[Still,] more leading-edge Medicare Advantage players will ultimately see the HRA as an extra resource that they have to use with their members anyway,” she said.

As easy as it is for healthcare providers to focus on conditions such as diabetes or congestive heart failure or lung disease, it’s equally important to realize that just because a patient has a particular condition it doesn’t mean they need a lot of services to keep them healthy.

For example, healthcare providers need to dig deeper with the patient who has shown up at the emergency room three times in the last six weeks, advised Alkema. Otherwise, she said, they have no way of knowing those falls are being caused by rugs or pets in the home in addition to the patient’s difficult-to-treat diabetes and the neuropathy in their feet that has become so painful that walking has become a challenge.

On the other end of the spectrum, Alkema referred to her own mother, who has three chronic conditions-none of which is diabetes-and rides 10 miles a day on her bike and is fully independent.

Her take-home lesson for attendees? You have to “look under the hood, almost on an anthropological level” to find out about what’s going on in patients’ homes in order to determine the services they need to keep them healthy-and manage costs appropriately.


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