Care with a side of comfort promises big savings in health costs
Feds could increase flexibility in how Medicaid, Medicare dollars can be spent
WASHINGTON _ As state and federal officials increasingly search for ways to curb rising health care costs, a decadesold idea is gaining traction: helping people with challenges that have nothing to do with medical care but everything to do with their health.
Insurers are taking steps as simple as paying for hot meal deliveries and outreach to homebound people and replacing air filters in homes with asthmatic children. More radical approaches include building affordable housing for people who don’t have a stable home of their own.
State and local experiments targeting factors like housing, transportation, food and other nonmedical services are flourishing as ways to improve people’s health while cutting costs.
But advocates and industry veterans say federal involvement could bolster those efforts. State leaders say the federal government also could increase flexibility in how Medicaid and Medicare dollars can be spent, as well as break down the divisions among housing, criminal justice, health care and other agencies that make addressing social problems challenging.
“So much can be accomplished leveraging successful public-private partnerships, but each side needs to do their part,” said Lucy Theilheimer, Meals on Wheels America’s chief strategy and impact officer. “Together, by addressing social determinants of health on a national level, we can not only provide the best possible care for our most vulnerable Americans, but also avoid more costly health care usage in the future.”
Proponents point to projects across the country as proof that addressing these so-called “social determinants of health” will help curb spending.
A health care nonprofit in Phoenix sliced monthly Medicaid costs by more than half, saving more than $4.3 million in one year, by constructing temporary housing for homeless patients who had nowhere to go after leaving the hospital. Research on Meals on Wheels America shows people who receive daily meals and interactions with other individuals have fewer hospital trips and save Medicare money.
The conversation and action around the issue has made its way to the national level.
The Centers for Medicare & Medicaid Services is investing in pilot projects and creating flexibility through value-based purchasing arrangements. Earlier this year, the agency issued guidance that opens the door for private Medicare plans to provide a broader range of supplemental benefits beyond the typical medical-related services, and a law that Congress passed last year affecting chronic care is set to expand those supplemental benefits beginning in 2020.
Advocates argue the new Medicare benefits don’t go far enough and note they apply only to people in the private plans known as Medicare Advantage. They are pushing Congress to invest more in legislation like the Older Americans Act, which is up for reauthorization in 2019 and helps fund services like meals, caregiver support and transportation.
Meanwhile, Health and Human Services Secretary Alex Azar recently hinted that the Center for Medicare and Medicaid Innovation will explore pilot projects to address social needs.
“What if we gave organizations more flexibility so they could pay a beneficiary’s rent if they were in unstable housing, or make sure that a diabetic had access to, and could afford, nutritious food?” Azar told an audience at the Hatch Center for Civility and Solutions in a Nov. 14 speech about the social determinants of health. “I want you to stay tuned to what CMMI is up to.”
The administration wants “to try out truly bold solutions to some of the most stubborn social problems our country faces,” Azar said. “What it will take is coming together and pushing the boundaries of what we have traditionally thought possible.”
In Phoenix, Sister Adele O’sullivan was working as a family doctor serving the homeless when she began to identify significant gaps in care.
Homeless patients had no easy way to hygienically clean and change bandages for open wounds. They didn’t readily have access to food necessary to take with medications. They weren’t getting enough sleep. Managing medication was nearly impossible for people with poor eyesight and no glasses.
So O’sullivan began stashing donated funds in a shoebox hidden in a medicine cabinet, eventually opening Circle the City, a nonprofit health care provider.
Today, the organization runs two respite centers that provide temporary housing and medical care to homeless patients when they are discharged from the hospital.
A two-year study of the program found that monthly per-enrollee Medicaid payments fell by roughly 56 percent in one year, according to a report by CMS and the National Health Care for the Homeless Council.
Investments like this not only improve people’s health but are also cost-effective, Circle the City CEO Brandon Clark said.
“This is one of the few arenas where we can actually do the right thing for people in a compassionate and human-oriented way,” Clark said. “(It) should be one of the most bipartisan movements on the table right now.”
Arizona Medicaid Director Thomas Betlach points to Circle the City and its respite care housing as one example of how addressing things like putting a roof over someone’s head leads to better outcomes and lower health care costs.
The state has funneled millions of its own dollars through its managed care companies to help address issues like housing, which federal Medicaid funds typically don’t cover. Health plans then work with local housing providers and other organizations that specialize in nonmedical services.
He notes his agency keeps housing and employment experts on staff who speak the lingo of those types of non-health care programs.
The Medicaid agency is also working with the state’s corrections department to help identify people preparing to leave prison or jail and sending that information to managed care companies, which can then proactively reach out to individuals and make sure they have health coverage when they’re released.
It’s really about coming up with strategies to break down the silos among various agencies, Betlach said. The federal government could assist, especially in helping data systems talk to each other, he said.
Financing is another area where federal officials could play a role in change, Betlach said. While Medicaid isn’t going to pay rent for every beneficiary, there may be a limited way to use some federal money to create stable housing for very high-cost people, he said.
The creation of homeand community-based waivers, or HCBS, is an example of how that can work, Betlach noted. The waivers help people live in the community instead of in institutions by paying for support services like home aides and case management. Institutional care is often more expensive.