Doctors and hospitals are often the faces of the healthcare industry and so they usually shoulder the blame for the problem of ever-growing healthcare costs in America, at least in the perception of the general public. Research shows that there are many contributing factors to the continuing trend of rising healthcare costs, and not all of them fit inside the traditional scope of medical care.
According to one case study, completed by the Partnership to Fight Chronic Disease, one of the major drivers in health spending is the rising prevalence of chronic illness. According to their research, 86% of the healthcare spending in Massachusetts is directly related to treating chronic illnesses. These costs will only increase as the number individuals with multiple chronic illnesses is expected to more than double by 2030. This increase has many factors, but one of the primary causes is the increasing rate of obesity in America; 40% of adults in America are now considered obese, a condition that often leads to chronic illnesses such as diabetes, hypertension, and pulmonary disorders.
While obesity can be linked to behaviors such as poor diet and lack of physical activity, these behaviors are not always a choice. Outside factors, such as food insecurity or lack of access to affordable healthy foods, often play into an individual’s dietary choices. Physical activity may be restricted by health, or by a lack of safe and affordable places to exercise. Outside factors, also known as social determinants, often play into both the development of and the management of chronic illnesses. For example, a lack of stable housing may aggravate existing chronic conditions by preventing a patient from being able to properly store and administer their medications. A language barrier may make understanding medical directions difficult. Limited access to transportation creates a challenge when asked to attend follow up appointments with a primary care physician.
Many patients face a reality where they suffer from one or more chronic illnesses while also experiencing any number of social determinants that create barriers to either receiving proper medical treatment or following through on prescribed treatment plans. This scenario often leads a patient to have high rates of emergency department utilization and hospitalizations. These individuals are known as “super users” because they incur much higher healthcare costs than the average patient. In fact, 5% of patients make up nearly 50% of the total healthcare spend.
What Can Be Done?
Community health programs across the country are seeing high rates of success as they implement programs that address patient health by coordinating both primary care and social service needs. In Connecticut, Project Access-New Haven is working to reduce the need for emergency room treatment and hospitalizations through the use of Patient Navigators. These Patient Navigators, also known as Community Care Coordinators, identify Medicaid patients who have an extremely high rate of emergency department use and then coordinate their care by scheduling and attending primary care appointments and then following up to ensure treatment plan compliance. As a result of the program, the emergency department rate for participating patients has gone down 22% and the hospitalization rate has dropped 48%. This has resulted in a cost savings of $153 per patient per month.
While many community care coordination programs are funded exclusively through either grants or Medicaid, Vermont has a statewide public-private partnership program that utilizes a model known as Community Health Teams (CHTs). These teams are made up of healthcare support staff that include health educators, social workers, dieticians, and nurse care coordinators. Team members are based throughout the state and they work with both participating primary care physicians and social services programs to help patients manage all aspects of their health, including economic, social, and behavioral factors. By facilitating both access to primary care and access to the resources needed to address social determinants, Vermont’s CHTs are projected to save the industry nearly 30% in incremental health spending over the next five years.
Stopping Chronic Illness Before It Starts
While some community health programs seek to manage chronic illness through care coordination, others strive to prevent chronic illness from developing in the first place. The National Diabetes Prevention Program (National DPP) is a research based lifestyle change program that is designed to help patients with prediabetes make the necessary lifestyle changes to lose weight and reduce the risk of developing type 2 diabetes. According to the Centers for Disease Control and Prevention, the structured lifestyle changes taught in the National DPP can cut the risk of developing type 2 diabetes in half. This model has also been adopted by other programs seeking to reduce the risk of chronic illness. YMCA gyms have begun offering a related program that is designed to address obesity, and the many chronic illnesses associated with it. Though the YMCA program is privately run, tuition will soon be eligible to be covered by Medicare.
Community health programs are showing that by employing care coordination models that address the many determinants of health, or by working to prevent chronic illness before it even develops, they can be solid, results-driven answers to many of the answers that face the modern healthcare industry. Particularly the dual challenges of improving the overall health of the highest-volume users and working to reign in skyrocketing healthcare costs.