Many Americans are unable to achieve their full health potential because of socioeconomic disparities, addiction, or even their address. To tackle these health inequities, health systems and health plans are testing innovative approaches that could bring financial benefits as well.
In an effort to bend the cost curve and improve population health, health plans and providers are actively seeking better strategies to care for underserved patients, such as those who live in rural areas, are homeless, or are addicted to opioids.
To a large degree, improving health equity for these groups means rethinking the delivery of health care so that patient needs are addressed further upstream, says Anne Weiss, managing director at the Robert Wood Johnson Foundation in Princeton, N.J. It also requires different financial models and an emphasis on collaborative partnerships with social services, public health agencies, and other groups.
Following are some innovations designed to improve health equity across the country.
Using Tech to Reach Rural Patients With Diabetes
Mississippi has the fewest number of active physicians per 100,000 residents in the country, according to the U.S. Census Bureau and the Association of American Medical Colleges. It also has an especially high prevalence of diabetes, with 13.6 percent of adults affected by the chronic condition, according to the Centers for Disease Control and Prevention.
To monitor and manage patients with chronic diabetes in Mississippi’s poor, rural, and underserved areas, leaders at the Jackson, Miss.-based University of Mississippi Medical Center (UMMC) are using remote monitoring via telehealth. “One of the primary reasons we drive telehealth as a solution is that we can deliver care a lot closer to home,” says Michael Adcock, FACHE (pictured at right), executive director of UMMC’s Center for Telehealth, which has been designated a Telehealth Center of Excellence by the Health Resources and Services Administration.
Remote monitoring helps UMMC providers educate patients with diabetes on healthier behaviors when the intervention is most likely to be effective—in real time. Patients whose glucose numbers jump significantly from one day to the next are flagged by nurses for intervention that day. One UMMC pilot study of 100 adult diabetic patients found that remote monitoring improved patients’ HbA1c measures by 1.7 percent while eliminating hospitalizations and emergency department (ED) visits during a six-month period.
Preliminary Results on the Mississippi Diabetes Telehealth Network
Payment for telehealth varies significantly by state, and Mississippi is one of the few states that provides true reimbursement for chronic disease management in the home via remote monitoring. Adcock believes that remote patient monitoring could result in significant cost savings across the country. UMMC’s pilot program of 100 adult diabetes patients saved $330,000 in six months due to decreased ED visits and readmissions. If 20 percent of Medicaid patients with diabetes were enrolled in the program, the state could save $189 million annually, he says.
Other remote-monitoring programs are underway at UMMC for patients with hypertension, heart failure, asthma, and high-risk pregnancies. Some programs, like one designed to educate adult kidney transplant patients, are not reimbursed but do cut costs from the system by reducing unnecessary readmissions and ED visits, Adcock says.
Providing Stable Housing
To address the lack of affordable housing in Portland, Ore., forward-thinking health system and health plan leaders are collaborating on the Housing Is Health initiative. One of those leaders is Eric Hunter (pictured at right), CEO of CareOregon, a health organization serving 275,000 Medicaid members. CareOregon and five major health systems—Adventist Health Portland, Kaiser Permanente Northwest, Legacy Health, Oregon Health & Science University, and Providence Health & Services-Oregon—are donating $21.5 million to build three separate housing complexes for the homeless.
The complexes will include nearly 400 housing units, as well as on-site primary care, urgent care, behavioral health, substance-use disorder treatment, palliative care, and pharmacy services. Residents also will have access to peer support and case management services to help them navigate through the healthcare system. Many of the residents will be recently discharged inpatients who will be offered temporary housing in 175 units that are available for transitional housing, so they have somewhere to recuperate. “We want to make sure they have a roof over their heads and have help with their nutrition and needs so they can actually heal,” Hunter says. Two complexes are slated to open later this summer and the third next summer.
Hunter thinks housing the homeless may have financial benefits that will accrue over time. A 2016 study by the Portland-based Center for Outcomes Research and Education (CORE) found that providing supportive housing to 1,635 individuals reduced annual Medicaid expenditures for the group by 12 percent, resulting in $936,000 in savings in the first year. Hunter attributes the savings to an 18 percent reduction in ED visits—even as primary care use increased by 20 percent.
Hospitals and primary care physicians also stand to benefit from the housing initiative by having a more stable population on which to be judged in value-based contracts, Hunter says. Still, he concedes that it may take years for CareOregon to realize any significant changes to its balance sheet as a result of the program.
Integrating Care to Reduce Opioid-Use Disorder
The opioid epidemic has been particularly hard on Maine, which had the highest prescribing rate of long-acting opioids in the country in 2012 (21.8 prescriptions per 100 people), according to IMS National Prescription Audit data. But that rate has been cut by nearly half as of 2017 thanks in part to provider education led by Portland, Maine-based Maine Behavioral Healthcare, a member of MaineHealth. More importantly, leaders at Maine Behavioral Healthcare are rethinking how they approach treatment for substance-use disorder in primary care.
“The majority of our success as an organization in serving our communities has been through our efforts to integrate behavioral health and addiction-related treatments into primary care settings,” says Stephen Merz, FACHE (pictured at right), Maine Behavioral Healthcare’s president and CEO.
One of Maine Behavioral Healthcare’s strategies is offering integrated medication-assisted treatment—an evidence-based therapy for substance-use disorder, employing one of three drugs—in its patient-centered medical homes. Leaders apply this strategy using a hub-and-spoke model that “operates under the premise that the majority of people should receive behavioral health services in an integrated way as part of an integrated delivery system, rather than as part of a segmented behavioral health system that is further separated from care for individuals with chemical dependency,” Merz says.
As part of this approach, MaineHealth has embedded 60 licensed clinical social workers in its medical homes to help identify and care for patients with opioid-use disorder. For the one-third of Maine Behavioral Healthcare patients with opioid-use disorder who require more-intensive treatment, specialized behavioral health centers called “hubs” are available. Each is staffed by a psychiatrist with specialized training in addiction medicine, licensed behavioral health clinicians and clinicians trained in treating patients with substance-use disorders, and recovery coaches/peers.
At the deadline for this article, MaineHealth had approximately 600 active patients with opioid-use disorder in its hub-and-spoke system. More than 800 have been served since Oct. 1, 2017. Leaders expect they will treat 900 altogether in 2018. One of the ongoing challenges for MaineHealth, which serves approximately 75 percent of the state’s residents, is the uninsured population. The state opted out of Medicaid expansion, and as many as 30 to 40 percent of MaineHealth’s patients are uninsured, Merz says. The state is piloting a new opioid health home model that includes a per-member, per-month payment for case management and other “wrap-around” treatment services for substance-use disorder that are not traditionally reimbursed under fee-for-service payment.
The model has had a slow start—just 100 or so patients enrolled in the first year—and some providers find the state’s staffing requirements restrictive. MaineHealth has expressed interest in the program, however, and Merz hopes the state will adjust the model and regulations based on provider feedback to encourage greater participation.
Lessons Learned
Experts offer the following advice to leaders who want to reduce health disparities in their communities.
Use the community health needs assessment. Hospitals are required to complete the assessment every three years and can use the process to identify which health inequities to target, Weiss says. MaineHealth identified substance-use disorder as a priority after reviewing its own assessment. Leaders may want to conduct this assessment jointly with other providers in their community.
Ask for help. Health system and health plans may want to reach out to community stakeholders like criminal justice, transportation, and business organizations to talk about potential solutions. For example, leaders at Maine Behavioral Healthcare work with law enforcement to train officers on how to identify individuals with mental health needs, including substance-use disorder, Merz says.
Think about the next generation. In addition to helping adults by funding stable housing, CareOregon aims to change the trajectory for children affected by homelessness. Hunter says that homeless children often have higher scores in Adverse Childhood Experiences testing, which raises their future health risks. “Housing is a big piece of a family’s economic security and helps to change the long-term dynamic,” he says.
Be a catalyst for collaboration in your own organization. In many provider organizations, internal leaders in finance, population health, and community benefits may not have had opportunities to interact. But a health equity project can be a good place to start. “What financial leadership can help do is bring some of those conversations together,” Weiss says.
Focus on the problem and then think about incorporating technology. Providers need to consider their clinical needs before they purchase technology platforms to address health disparities, UMMC’s Adcock says. In addition, they should realize that one product will not address every issue.
Thinking Beyond the Bottom Line
Not every investment in improving health equity will generate cost savings in the short term. At the same time, those investing in change may not always be the stakeholders who reap the most rewards. But focusing just on the money misses an opportunity to drive significant change and improve the health of the community, Weiss (pictured at right) says.
“I think most of us have just always assumed that if we get at social problems upstream, we should be able to see better health outcomes and reduce spending, but we have to think about those two things differently,” she says. “It is an important goal to improve health outcomes, even if the savings take a long time to materialize or don’t always affect our own bottom line.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article: Michael Adcock, FACHE, executive director, Center for Telehealth, University of Mississippi Medical Center, Jackson, Miss.; Eric Hunter, CEO, CareOregon, Portland, Ore.; Stephen Merz, FACHE, president and CEO, Maine Behavioral Healthcare, Portland, Maine; Anne Weiss, managing director, Robert Wood Johnson Foundation, Princeton, N.J.
