By Lauran Hardin, Elizabeth Métraux, Dawn Wiest, The National Center for Complex Health and Social Needs
Two hundred hours, 20 flights, and interviews with more than 50 leaders representing care delivery in 30 states. Through a grant from The Commonwealth Fund, a private foundation whose mission is to promote improved access and outcomes for society’s most vulnerable, our team from The National Center for Complex Health and Social Needs has been on a quest to understand how health care leaders are working to adjust their business models to care for the most complex and high-cost populations in the nation. While the moral case to improve care for patients with complex needs may be irrefutable, the practical challenges of making dollars align is a far harder puzzle to solve.
Here are 10 insights from our research that offer current leaders’ perspectives into the emerging field of complex care, and how we work to solve its so-called margin-mission tension.*
1. High-cost patients repeatedly return to the hospital because hospitals repeatedly treat the wrong thing.
Treat, release, treat, release, treat, release. Thirty times. Who are we really helping? We have to step back and say, ‘How can we really make a difference for better health, better care, and lower costs for this person?’ It turns out that it isn’t about just relating to them when they enter the emergency room, but connecting them with a community health worker so other social needs are met.
— Ben Carter, COO, Trinity Health
Clinical interventions on an episodic, transactional basis are not making America healthier. Is it our job in America to be healthier with compassion, or is it our job to do spot medicine?
— Scott Reiner, CEO, Adventist Health
2. Payers’ need for standardization often conflicts with providers’ need to “do the right thing” for complex patient populations.
While we’re dealing with unpredictable human beings that just don’t fit a single approach, payment models essentially treat everybody the same. So it's a collision of funding and the reality of what a patient needs. If we had the money and the time to create a program that actually meets the needs of individual patients, it would be successful. We don’t have that luxury.
— Margie Powers, Principal, Margie Powers Consulting
There is no payer saying, ‘Today you cured loneliness or hunger; let me reimburse you for that.’ Funds that support this work come from our own budget and margin because compassionate care is what our mission is all about.
— Mouhanad Hammami, M.D, SVP, Safety Net Transformation, Community Benefit, Health and Well-Being, Trinity Health
Models for complex care coordination will only be successful if we can move to total cost of care risk quickly; payers aren’t there yet. Most payers just haven’t done this, so it’s difficult for them to get their heads around the concept. They want fee-for-service, which doesn't allow us to make the investments or do what we think is most important.
— Melanie Bella, Chief of New Business and Policy, Cityblock Health
3. While the shift to value-based care is seen as an opportunity for innovation, the transition from fee-for-service to value is really hard. Leverage the “inevitability of change.”
We’ve lived for 50 years in a fee-for-service model, and we’re having to pull away from that now. The complexity lies in that separation. And letting go of one to go to the other, that's really hard work, particularly when the world — the whole economy — is vested in that old model.
— Ben Carter, COO, Trinity Health
The work-around that everyone is using is the specter of value-based payment. It's like, ‘Look, this is going to be here, and you don't want to be caught without a plan. I've got a plan for you.’ That's really what the conversation is about. Even if there is a little bit of a revenue hit, that's why we're here. We need to work with finance to find revenue so we can do what's right by our patients.
— Dave Chokshi, MD, former Chief Population Health Officer, NY Health + Hospitals
4. For value-based arrangements to work, we need to widen the aperture on what we mean by value, how to measure it, and whether return on investment (ROI) is an appropriate framework for evaluating success.
Return on investment inherently forces you to think about a specific timeline — usually six months or one year. That biases us towards specific types of actions which may not be the most impactful.
— Anand Shah MD, VP Social Health, Kaiser Permanente
New York State is pushing value-based contracts to include components of work around social determinants, so you have to prove that you have some sort of subcontract with a community-based entity in your value-based, risk-based contract. They're also pushing payers to incorporate those subpayments in total costs. That’s where it gets complicated. There’s really no precedent for developing a fair market value for that work — around nutrition, for example.
— Kristen Mucitelli-Heath, St. Joseph’s Health, a member of Trinity Health
With complex care, you can't take one model and have everyone do the same thing. There's always customization and trial and error of what works in your community. So you've got to have time to do that experimentation and the freedom to make mistakes. We do five-year contracts and nothing less because that's how long it takes to figure out the numbers and show an ROI.
— Margie Powers, Principal, Margie Powers Consulting
You have to be able to articulate what really changes with the ROI. You've got to be able to tell the story, no matter how hard or incomplete it is. A lot of people need that perspective for validity. And it may not be the tightest ROI, but at least you've struggled through it. Then they’re willing to listen to the rest of it.
— Gay Landstrom, SVP and CNO, Trinity Health
5. Cross-sector, cross-community partnerships are a necessary component of the work.
We know what a patient’s health care utilization is, and we can extrapolate those health care costs. But they're also costing the Department of Corrections money if they’ve been incarcerated. And they're also costing the Department of Homeless Services money because they've been in shelters. So the big bottom line for a person should occur across those various systems, and the power of that is that then you have a bigger pot of money. You can make the case that if we do better by these people, then we're going to save not just health care dollars, but all dollars. We haven't quite gotten there yet.
— Dave Chokshi, MD, former Chief Population Health Officer, NY Health + Hospitals
Multiple systems are broken. The social services systems are hard to use. The behavioral health systems are hard to use. We are hard to use. To address systemic issues that add to the problem we're all trying to solve, you have to call everybody to the table.
— Susan Cooper, MSN, RN, FAAN, Chief Integration Officer, Regional One Health
As a health care system, we cannot do everything. We don’t have shelters to run for the homeless. We don’t have soup kitchens or community gardens to address food insecurity. But we can support those programs in the community. We can partner with whoever is working at that, because they probably know better how to do it well.
— Mouhanad Hammami, MD, SVP, Safety Net Transformation, Community Benefit, Health and Well-Being, Trinity Health
6. Making the case for investing resources in working with people with complex needs requires understanding the different “mental models” of stakeholders.
Leaders like chief nurses need to be translators. They need to understand other languages in order to translate the story to people who have never been in a clinical setting and don’t know this world. Other people grew up with a different mental model. Physicians, nurses, finance. You have to understand them enough to understand their framework.
— Gay Landstrom, SVP and CNO, Trinity Health
The biggest thing is to know your audience and be prepared to say, ‘Okay, this person's going to give you pushback.’ Before I go into any meeting, I talk to regional leaders to ask, ‘What do I need to prepare for this person?’
— Sarita Mohanty MD, Vice President for Medicaid and Vulnerable Populations, Kaiser Permanente
When I meet with leadership, my goal is not to get everything I want. My goal is to implement something that is going to cost more money to undo than it is to improve. That’s a compelling argument.
— Torrie Fields, CEO Votive Health
7. Much of the resistance to supporting complex care programs is based on misperceptions about the impact of these programs on the bottom line.
I often hear finance teams say things like, ‘We're not allowed to use Medicaid dollars in this way,’ or ‘The state won't recognize that expenditure.’ These statements are rarely true. Just look at something called ‘in lieu of benefits,’ something a lot of CFOs are unfamiliar with. There are opportunities for health plans to do important complex care coordination in partnership with the state and not get penalized. When you're the person inside the organization trying to get an investment made, I don't think your voice carries as much weight as if it's one of your competitor plans, or somebody else in the world of finance saying, ‘Oh yeah, this is allowed. We do this. It works. There is a return on the investment.’
— Melanie Bella, Chief of New Business and Policy, Cityblock Health
8. Leadership support is essential to launching and sustaining programs.
Our willingness to take risks in order to care for complex populations had to come from our most senior leadership, saying, ‘This is who we are as an organization. We're going to do this.’
— Sarita Mohanty MD, Vice President for Medicaid and Vulnerable Populations, Kaiser Permanente
When the program is a little standalone off to the sides, doing good work, but in isolation, it's not going to take off. And the people running it will get really frustrated because they never reach scale. There has to be organizational support, and it has to be part of the culture and mission.
— Margie Powers, Principal, Margie Powers Consulting
9. The health care workforce wants to do the right thing. Unfortunately, many practitioners are working in systems that don’t support them.
The feelings that lead people to go to medical school are often the same feelings that lead them to want to provide care to our most vulnerable patients. The more that we can integrate compassionate care into the fabric of a health care organization, the better we’ll do with keeping our workforce engaged, productive, and effective.
— Mark Schuster, MD, PhD, Founding Dean and CEO, Kaiser Permanente Bernard J. Tyson School of Medicine
10. Stories matter.
With all the wisdom imparted and insight gleaned, perhaps the most enduring takeaway from our travels was the immutable, peerless power of stories. Susan Cooper, Chief Integration Officer for Regional One Health in Memphis, Tennessee, beautifully summed up this work: “Our power is our narrative — not our numbers. Numbers are really great, yes, and important. But stories turn on light bulbs. When you sit at the table and you tell Billy's story or Janet’s or Eleanor’s, we stop. We listen. And when we’re lucky, we get to change the story. That’s the job of health care professionals.”
* Excerpts have been edited for clarity and length.