Social Determinants

Progress in addressing the needs of Medicaid and “dual-eligible” patients

Elizabeth Gardner | March 28, 2019

Key Takeaway: Patients who are covered by both Medicare and Medicaid are among the most complicated in any provider’s population. Effective strategies for addressing their needs—both medical and non-medical—are essential for improving care and reducing costs.

One in five U.S. residents receive their healthcare coverage through Medicaid, and many of them face economic and social challenges that can injure their health and increase the cost of their care. About 15 percent of people covered by Medicaid are also eligible for Medicare coverage. “Dual-eligibles” are some of our most medically complicated: 68 percent of them have three or more chronic conditions, according to the Centers for Medicare and Medicaid Services. More than 40 percent have a mental illness diagnosis, and their annual per capita healthcare costs are about double those of a Medicare-only patient. About half of dual-eligible patients need some type of long-term support, whether institutional, community-based, or home-based.

If the healthcare system can intervene effectively to make Medicaid and dual-eligible patients healthier, those interventions can have a significant impact on the nation’s health and its healthcare budget, said panelists at the Health Summit 2018 session “Medicaid & Duals: Can We Scale What’s Needed?”

But first, we need to understand who they are, said panelist Iyah Romm, CEO and co-founder, Cityblock Health, a 2017 startup that works with payers and providers to connect their patient populations with essential community supports. The company is currently partnering with New York insurer EmblemHealth to improve the health of enrollees in the Crown Heights neighborhood of Brooklyn by providing them with flexible access to many kinds of care and help with their social needs, including a “community health partner” for each patient who serves as a point person.

“We know very, very little about the people that we are seeking to care for in this setting,” said Romm. “We have now discovered public health—probably four decades too late—under this buzzword of ‘social determinants of health.’ I think there is a massive opportunity for understanding the people that we’re seeking to care for, aggregating data from soft notes and electronic health records and a variety of other sources.”

Mining all the available data may yield surprising clues to how to reach people. For example, when Romm ran a crisis stabilization unit in Massachusetts, patients often made a beeline to the facility’s public computer to check in with Facebook—even when mired in addiction or a psychiatric crisis. “These are technology-literate, engaged, highly communicative populations that are looking for ways to access supportive services that are focused entirely on how you build relationships,” he said. They might not be able to get themselves in to a specific appointment, but they could benefit from services offered electronically or advice from a community-based health worker. “How do you understand what people actually need, and how do you do it in very light-touch, always-available ways?”

Kate Walsh, President and CEO, of Boston Medical Center, described a “therapeutic prescription-driven food pantry” that BMC started 15 years ago for patients whose health is threatened by hunger. It serves 7,000 patients a month, helping them bridge food emergencies. The BMC health system also includes the BMC HealthNet Plan, a Medicaid Managed Care Organization with more than 300,000 members and Boston HealthNet, a network affiliation of 14 community health centers throughout Boston. Walsh said preliminary data suggests that 3 percent of the MCO patients account for 40 percent of the costs, and bending that cost curve will entail finding out what’s driving the excess costs for those patients.

“We do a ‘thrive screen’ where we ask patients about food and security, housing, education, utilities,” she said. “Where can we make investments where we can actually have an impact?” BMC has used $6.5 million to make five experimental investments in housing, with a variety of partners, as a way to focus its public health expenditures where they will do the most good. Partnering is essential, she said. “The last person you want building beds is a hospital executive—we can’t build a bed for under $1 million.”

Blue Cross Blue Shield of North Carolina is investing $50 million to address social determinants of health, and it plans to partner with both health care providers and social service agencies, said President and CEO Patrick Conway, MD, who directed the Center for Medicare and Medicaid Innovation from 2011 to 2017. The not-for-profit organization currently insures the majority of North Carolinians, either directly or as contractor for Medicare and state government, and is in the process of bidding to manage care for the state’s Medicaid population as well.

Conway said addressing patients’ larger needs can help all Blue Cross enrollees. “We are not thinking of our investment in this care model at a line of business level, but as something that will work across lines of business,” he said. With a majority of the population covered, BCBSNC can achieve continuity that eludes national payers: for example, if patients move from commercial insurance to Medicare or Medicaid, they can continue all of their relationships with providers or social programs. “As people move business lines, we are still caring for them,” Conway said. “And I think that matters.”


About the Author

Elizabeth Gardner, Staff Writer