Why Those Interested in Population Health and ACO Development Need to Think About the Dual-Eligible Population

Oct. 5, 2016
My interview with Dr. Salil Deshpande of United Healthcare of Texas during the Health IT Summit in Houston offered insights into some of the opportunities around care management going forward

It was excellent to be able to interview Salil Deshpande, M.D. last week, during the final session of the Health IT Summit in Houston, sponsored by our sister organization, the Institute for Health Technology Transformation (iHT2). I was hoping that Dr. Desphande, chief medical officer of the Houston-based United Healthcare Community Plan of Texas, a division of United Healthcare of Texas, might be able to offer some insights on some of the populations that United Healthcare serves in Houston and across Texas, and he indeed was able to do so.

I was particularly interested in Dr. Deshpande’s insights around the Medicare/Medicaid dual-eligible population. That is a population with very intense needs and extremely difficult situations, with many elements that are not strictly clinical, but rather, involve socioeconomic and other factors. I’ve been writing about care management for dual-eligibles for nearly 20 years now, and it is in fact the combination of clinical issues and often very intensive social determinants of care and care management, that makes it so challenging to care for these health plan members/patients.

As Dr. Deshpande told our audience last Wednesday, “[T]o step back for a moment, that emphasis on dual-eligibles, it is something that is a priority for the health plans. I think the focus and the eye on healthcare will continue for the country as a whole. It is obviously an issue that the payer industry is also very focused on. There’s been increased access to healthcare for the past several years. We expect that additional people will continue to move into the insured category. There are still continued pressures around healthcare costs in general, of course, but of those reasons will underlie why we are continuing to focus on healthcare as a society.”

He added that, “In terms of the cost pressure, that issue is particularly relevant among the dual-eligible population. They are among the sicker people, and are either elderly or have qualified for SSI by virtue of some other disability, and also are likely to be living below the poverty line. And they likely have a history of lack of access to care, that has caused their chronic conditions to be under-diagnosed. And for all those reasons, that patient population tends to be an expensive one, but with opportunities for healthcare improvement. That is the reality for any population,” Dr. Deshpande noted, “but more dramatically in the elderly population and among relatively poor populations; in both cases, a relatively small percentage of members are driving the expenses. So to the extent that we can drive care management, we will both improve outcomes and lower costs, and thus, the focus on dual-eligible members makes eminent sense.”

What’s interesting for me about my discussion at iHT2 with Dr. Deshpande is how for years, health plan care management of the dual-eligible population was seen as something very specialized, something very difficult and challenging, and not even something that most health plans expended a lot of energy on. Certainly, few providers were focused specifically on that high-needs group.

And yet now, as healthcare costs in the U.S continue to increase, and as American society ages and chronic illness continues to explode, what is really interesting is this: I believe that the health plans whose success in managing the care and health status of their dual-eligible members—people who are usually elderly and impoverished and very often in quite poor health—will be able to help show the way for everyone with regard to how to manage the care of all types of populations, in the emerging health care system—one in which providers and plans will have to work with relatively fewer resources while managing more complex, challenging health status, care management, and patient care situations.

Indeed, the forward evolution of accountable care organization (ACO) and population health management development, is beginning to make what has been learned so far in the care management of dual-eligibles quite timely and relevant—even though some health plans began working more extensively with that population years ago.

I remember researching and writing an article 20 years ago for a managed care-focused publication about the innovations then taking place among a smallish number of health plans around the care management and case management of its dual-eligible members. It was fascinating, in doing the interviews for that article, to speak with one of the care management executives at one health plan that had made considerable strides with the care management of that plan’s dual-eligible population. She noted that going into the homes of members and checking for hazards, including fall hazards, was one of the things that was absolutely necessary to do, in working to support her organization’s dual-eligible population. In some cases, she and her colleagues were even having handrails installed, in order to avert potential falls that could lead to hip fractures, for example.

And as I’ve heard numerous industry leaders attest to in presentations and interviews since, it is success with the care management of those very members that could help healthcare executives, managers, and clinicians succeed with other populations, and with population health and accountable care more generally. And that is especially because such success relies on bringing together all the elements of a complex ecosystem of interactions, encompassing health risk assessment-driven analytics and the analysis of both clinical and claims data, the implementation of solid, team-based and IT-facilitated care and case management, authentic patient engagement, and also the engagement of clinicians, especially physicians, and their commitment to complex care management and operational improvement processes over long periods of time, on behalf of defined individuals.

There are of course obvious reasons why until recently these kinds of processes had not taken root broadly across U.S. healthcare. As Dr. Deshpande told me and the assembled iHT2 audience in Houston, “Historically, healthcare has not focused on non-clinical issues, and yet those people who lack shelter, who do not have a steady job, or the income to buy groceries regularly—they are not paying attention to their prescriptions, because frankly they have other priorities; and so they are ripe for care management. So those are significant opportunities,” he added, and went on to emphasize the importance of strong analytics tools and processes in addressing these issues.

How quickly will the learnings from this kind of work spread across U.S. healthcare? The answer to that depends on a number of factors. But what is clear is that the work that has been put into the care management of dual eligibles to date deserves a good, long look, on the part of everyone who is working to improve the care of—and the health of—all Americans. And healthcare IT leaders will absolutely be front and center in all this, in helping to facilitate the selection and implementation of information systems to support the many complex elements of this kind of work, going forward.

So those who haven’t thought lately about Medicare/Medicaid dual eligibles might want to reconsider that population, as a bellwether group with regard to the success of our nation’s healthcare system more generally.

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