Insights on the Value Case for Complex Care: Lessons from the COVID-19 Pandemic


By Lauran Hardin and Emily Wasuna, Camden Coalition’s National Center for Complex Health and Social Needs

A little more than two years ago, we set out to learn how health care leaders from more than 30 states adjust their business models to care for the nation’s most complex and high cost populations. A year later, amid a global pandemic, our team from the National Center for Complex Health and Social Needs reconvened the same health care leaders to learn how the COVID-19 pandemic and racial disparities in health outcomes impacted their complex care business models. This exploration was made possible through a grant from The Commonwealth Fund.

1. COVID-19 has brought into sharp relief the socio-economic drivers of disparities in health access and outcomes.

We’re known for treating the vulnerable, the weak, the frail, the elderly. It was stunning how that population had a much more sustained burden of disease than what we saw for other populations, and the disproportionate impact on people of color. 

- Arby Nahapetian MD, SVP and System Medical Officer, Adventist Health

The notion of social context informing care, quality, and outcomes is on some level intuitive, but not always well-specified. COVID actually made that very clear. Someone who is experiencing homelessness and needs to be isolated is going to have a much harder time. We know if they don't isolate, that's going to have downstream clinical impacts for their family, and their neighbors, which is going to have cost implications for anybody who's managing a population. The connection between social context and likely cost and clinical outcomes for an individual or population has become much more understood.

- Anand Shah MD, VP Social Health, Kaiser Permanente

We have a system now [that] is working perfectly to get the outcomes that it actually gets: giant life expectancy gaps. What COVID did was just reveal in a very, very short period of time what's been going on for hundreds of years.

- David Ansell MD, MPH, SVP Community Health Equity, Rush University Medical Center

2. Financial uncertainty stemming from the COVID pandemic is reshaping how health systems are thinking about and planning for their financial future.

Strictly from the financial perspective, let me first say that it's been disastrous. The combination of lost elective cases and revenues with escalating costs has been devastating. Without the federal COVID CARE Relief Act and the monies that have been provided to us, I don't think we would still have the doors open.

- Rick Wagers, Emeritus Executive Vice President and CFO, Regional OneHealth

In the early stages of the pandemic we didn't build a budget - things were changing too quickly.  Instead we're doing quarterly forecasts. That's a first for us [and] means we're talking with finance all the time.

- Gay Landstrom PhD, SVP and Chief Nursing Officer,  Trinity Health

We're building COVID out as a service line versus a crisis because in the end, it's an infectious disease. We've treated thousands of patients now. There is a normal cadence to it. We know what the condition looks like, how they present, which medications help manage, which ones don't, and we know how to isolate. So we're learning what the costs are. We're trying to figure out what site of care is best for treatment - the best spot, best location, best timing.

- Scott Reiner, CEO, Adventist Health

3. A focus on mission helped sustain momentum and foster innovation throughout the pandemic.

You might think that we would retract, just try and hunker down, and survive. But at the same time, I think it caused us to really ask ourselves, 'okay, what are we here about? Should we survive if we're not focused on our mission?' So we really redoubled our commitment to caring for the people who are poor and vulnerable, particularly populations of color. All the unrest and the diversity and inclusion issues that have really been rumbling have caused us to look deeply and figure out what we are really here for. And if we don't fulfill that mission, should we even continue? 

- Gay Landstrom PhD, SVP and Chief Nursing Officer,  Trinity Health

It is so incredibly hard during a challenging time, like a pandemic, to stay true to your values. Having a true north in our moral conscience and people in the institution that pressure you to stay true to that is crucial. This is a time where there are so many external forces on health care and it may not be the easiest financial decision to stay true to that. 

- Omar Lateef DO, President and CEO, Rush University Medical Center

4. Complex care provided — and continues to provide — an important foundation for adapting and responding rapidly to the COVID crisis.  Relationships in the community facilitated this work, while new connections were created to care for at-risk individuals that may not have been so easily forged in non-crisis times.

I’m so grateful we already started this work because it really did lay a foundation. We already had relationships to build on, so we were able to jumpstart a lot of work related to COVID.  Everything we did to build the strength of this team around complex care was translatable to a lot of the core functions that had to be built quickly for pandemic response. 

- Susan Cooper RN, SVP and Clinical Integration Officer, Regional One Health

A relief effort like what we did just doesn't come overnight, because it's so hard to get people just to work together and put egos aside. A lot of this has been built over the years of just being out there, building up relationship credits, creating programs and activities, so that when a crisis hits, you're already a trusted partner and resource in the community, which makes it a whole lot easier to mobilize. 

 - Cesar Armandariz, former Community Benefit Director, Adventist Health

There was a lot of great instantaneous work that happened in our communities because we had spent the last four years really understanding their needs and engaging partners and residents who were really able to swiftly activate. And it's not surprising that COVID testing and vaccination efforts got up and running faster in several of these communities because the relationships already existed with the health system and with partners. At the end of the day, if you have the relationships you can do anything. It doesn't matter what the problem is, you can fix it.

- Jaimie Dircksen, Vice President, Community Health & Well-Being, Trinity Health

5. Value-based payments provided the flexibility and consistent resources to respond to the pandemic and continue serving medically and socially complex populations effectively and efficiently.

One of the things that we learned is that value-based approaches fared pretty well through this pandemic. When I say fared well, I’m talking about financially because we had a steady flow of cash and income, and it allowed us to focus on other ways that we can reach out to the communities that we serve, through telehealth, care coordination, and so forth. The flow of funding was there to actually do even more of that type of work.  

- Ben Carter, COO, Trinity Health

Very quickly we stood up what we call our community rapid response program...we couldn't leave our members in the lurch. It forced us to be very nimble and put programs in place that will stay after COVID because they're very important for our members. We got to them more quickly than we otherwise would have. We would not be able to do these things were we not in a full-risk arrangement with that flexibility and that nimbleness to move quickly and not to be reliant on volume. Being able to flex our care teams, use telehealth, drop off PPE bundles and devices to our members… COVID has probably reinforced the need for these types of models and allow us to make a policy case for why several of these things should stay intact.

- Melanie Bella, MBA, Head of Partnerships and Policy, Cityblock

What's been fascinating is when you look at some of the other health systems that have really maximized the fee-for-service environment, their pivot is going to have to be so huge in terms of pendulum swings, and fascinatingly they've been the ones calling for advice the most

- Arby Nahapetian MD, SVP and System Medical Officer, Adventist Health

6. Complex care’s success in reducing reliance on acute care proved invaluable during the pandemic and points to new opportunities for cost savings and revenue creation.

The population health muscle we had built meant we knew what to do to care for people at risk for the impacts of COVID. It may have been a different group of people, and different medical interventions, but we had well-honed care management interventions and we were able to deploy those.

- Emily Brower MD, SVP Clinical Integration and Physician Services, Trinity Health

Opportunity costs — when you take volume out, whether that's in the emergency room that keeps you from going on diversion, or it takes people out of the inpatient beds — creates capacity that you can put others into those resources that really need them, like those who need care for COVID. Complex care programs can contribute to this shift.

- Rick Wagers, Emeritus Executive Vice President and CFO, Regional One Health

Services like palliative care and home-based primary care are really there to treat the suffering in the system rather than the suffering of the patient. It does treat the suffering of the patient but the only reason that you save money with these types of services is because the system that tries to help these people is broken, and that is clear now. Before, we were looking for cost savings from the patient rather than the population. Rather than how can I save money from palliative care, if you look at how palliative care saves money for the system, then you have a very different business case. I think that business case is what's needed to respond to COVID.

- Torrie Fields, Chief Executive Officer, Votive Health

7. The intersection of COVID with the Black Lives Matter protests and broader social justice movement has reinforced the need to shift and expand how we measure quality and outcomes in health care.

Health equity and quality measurements are more central today. Addressing social context is one way to help create equitable outcomes. While I don't know that I have new data around financial returns, I think it's allowing folks to look for returns in quality outcomes or equitable outcomes, which are a different kind of impact and increasing the impetus for this work. 

- Anand Shah MD, VP Social Health, Kaiser Permanente

Traditionally we've looked at avoidable high-cost utilization.  I would say that the definition of what appropriate care is, as we look at ways to address complex care and our care management efforts, is constantly changing.  One thing that is evolving is the need to capture more patient reported outcomes, as well as provider and staff satisfaction. I also see a lot of needed emphasis on addressing burnout. How do we develop care teams in a way that people will find joy in their work, so that they're feeling they're doing things at the top of their license?

- Sarita Mohanty MD, MPH, MBA, former Vice President, Care Coordination for Medicaid and Vulnerable Populations, Kaiser Permanente now President and CEO of The SCAN Foundation

We are measuring all of our social care encounters in every kind of slice that you can imagine. The kinds of encounters, the racial/ethnic background of the individuals served, but our primary outcome that we will ultimately measure is reducing preventable hospitalizations. So, the conditions that people should never be showing up at our emergency department or our hospital for is what we are working to prevent from happening. That is our ultimate measure of success.

- Jaimie Dircksen, Vice President, Community Health & Well-Being, Trinity Health