The country’s most vulnerable patients often fail to obtain the care they need, but it doesn’t have to be that way. Ensuring that these people receive necessary services isn’t just the right thing to do — it also goes a long way toward lowering the nation’s health care costs. That’s because those with chronic conditions, such as asthma and diabetes, are typically frequent users of the health care system.
Roughly a quarter of Americans have multiple chronic conditions. The cost of treating patients with multiple chronic conditions throughout the United States constitutes 71% of all health care expenditures, according to the American Journal of Preventive Medicine.
These individuals could very well be some of your employees. Fortunately, value-based care offers a viable approach to addressing their needs.
Why We Need to Pay Attention
A recent DaVita white paper makes the case for value-based care for the most vulnerable: “Patients who receive high-touch, personalized care are less likely to delay essential care and less likely to go to the emergency department for non-urgent care, thus less likely to accrue avoidable costs.”
In 2016, DaVita partnered with a large regional health plan to help manage its most vulnerable members. For the purposes of the case study, DaVita described its “most vulnerable” populations as those with:
- Four or more high-risk chronic conditions per patient.
- 650 hospital admissions per 1,000 patients.
- 800 emergency room visits per 1,000 patients.
DaVita Health Solutions established a community-based medical group of experienced providers to deliver medical, psychosocial and behavioral care within members’ homes, as well as in transitional care settings — all of which they supported with 24/7 care coordination and support. The model included annual health assessments, individual care plans, coordination with physicians and community resources, and medication reconciliation and management.
In the first year, Davita reported:
- 10-15% fewer ER visits.
- 35-40% fewer hospitalizations.
- A 15-20% lower cost of care.
Who Are the Most Vulnerable?
There’s no single definition of “most vulnerable.” However, as the DaVita study population illustrates, those in a position of vulnerability rely heavily on health care services — meaning that across the board, they have room to vastly improve their health outcomes.
But patients with high health needs aren’t necessarily considered “vulnerable” automatically. Other, nonmedical factors — known as social determinants of health — also come into play. These can be loosely defined as the conditions in which people grow, live, work and age. It’s true: Location matters.
These social determinants can affect people’s financial security and lead to costly differences in the health care, food, transportation and other resources. These disparities account for roughly $93 billion in excess medical care costs and $42 billion in lost productivity per year, according to the Kaiser Family Foundation.
Low-income people are particularly vulnerable. They are less likely to receive recommended preventive care and more likely to visit the emergency room or wind up staying in the hospital for a condition that could have been treated elsewhere. They are also twice as likely to have behavioral health problems as those with higher incomes and 10 times more likely to experience food insecurity, according to the Commonwealth Fund.
Certain communities are just as much at risk. The American Hospital Association created a list of what could indicate a vulnerable community, including:
- Lack of access to primary care services.
- Poor economy.
- High unemployment rates.
- High rates of people who are uninsured or underinsured.
- Social, cultural and language barriers to accessing care.
- Low education levels.
- Environmental challenges, including unsafe streets and few or no places for exercise.
Of course, this varies by location across rural, urban and suburban areas. Each region has its own mix of challenges.
Meeting the Need
Over the last decade, payers and policymakers have turned their attention to the impact of social determinants of health. Providers and community leaders have long recognized that if a patient’s basic needs aren’t met, they’re not likely to stay healthy.
Two of the primary emphases of value-based care come into play in meeting vulnerable patients’ needs:
- Health care, not sick care. Value-based models center on whole-person health care — specifically, preventive health care. In a value-based health plan, individuals generally receive more preventive care and are more likely to stick to their care plans than patients in fee-for-service plans. A TriHealth/Anthem value-based partnership led to increased preventive care and lower costs for employers.
- Coordinated care. Physicians are paid for the value they provide, not the volume of work they do. Because they have incentive to share data with each other, clinicians have a better view of the whole patient. They’re also able to collaborate with case managers, social workers and other providers to find appropriate community resources.
Employers have their own role, as some employees may be vulnerable patients. Their higher rates of illness may lead to increased health care costs; meanwhile, absenteeism and presenteeism can damage productivity.
The most important thing you can do now to offset these issues is to offer effective coverage. From there, look for a plan design that addresses the needs you anticipate. For instance, look for plans that offer robust behavioral health services. If your employee base is largely rural, search for plans with a telemedicine option. Work with an insurer that provides easy-to-understand tools to help your employees select the best plan design.
Encourage employees to be smart consumers. You could simply remind employees to choose in-network health care providers, review all the costs for a procedure and ask for generic medications, or go further and incorporate financial literacy into your wellness offerings.
Above all, be flexible: Give your employees the time they need to take care of their health, as they may have limited time or access to services after work, depending on where they live.
The Bottom Line
Both you and your employees want lower health care costs without sacrificing your well-being. Patient-centered, value-based approaches to patient care delivery and payment make it possible to focus on improving health care upstream, avoiding costs down the line for everyone.