At the Intersection of Health, Health Care and Policy

Cite this article as:

Bara Vaida
For Super-Utilizers, Integrated Care Offers A New Path

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Health Affairs 36, no.3 (2017):394-397
doi: 10.1377/hlthaff.2017.0112

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Entry Point
pital or the emergency department (ED)
multiple times in a year. These super-
utilizers of health care are among the
5 percent of patients that account for
more than half of US health care spend-
ing, according to the 2012 Medical

Downloaded from http://content.healthaffairs.org/ by Health Affairs on March 7, 2017 by HW Team

Expenditure Panel Survey.1
What we are learning is that we can
take better care of these individuals, but
it takes new and more proactive strate-
gies, Brenner said as he announced
the creation of the National Center for
Complex Care and Social Needs, which
aims to be a clearinghouse for ideas and
training. It demands a new paradigm
of care.
Brenners coalition model, made fa-
mous among health policy leaders by a
January 2011 New Yorker article titled
The Hot Spotters,2 is one of the dozens
that health systems, payers, and states
are testing around the country. The
strategies have mushroomed as Medi-
care, the federal health program for
Managing care: At the Camden Coalitions offices in Camden, New Jersey, a care management those older than age sixty-five, and Med-
team composed of nurses, community health workers, and case managers meets regularly to icaid, the federal and state health pro-
coordinate care and manage the needs of their most complex patients. From left to right: gram for low-income individuals, have
Jeneen Skinner, Ebony Hailey, Gladys Antelo, Sharine Eliza, and Jessica Cordero.
embraced new payment strategies tying
dollars to better patient outcomes. State
doi: 10.1377/hlthaff.2017.0112 budget constraints are also driving gov-
ernors to look for new ways to rein in

For Super-Utilizers, health care costs.

Many models are showing promise,
but which strategies are the most effec-
Integrated Care Offers tive for addressing super-utilizers re-
mains unclear. In general, all of the

A New Path models involve expanding a patients

care from a single provider to an inte-
grated health team that includes access
Many health systems continue to experiment with the best way to care to behavioral health and social services
for those patients who end up in the hospital most frequently. such as food, housing, and transporta-
tion. Often the care team will then follow
BY BARA VAIDA
up with patients repeatedly to make sure
they get the care they need.
This is about realizing that peoples
health can benefit by addressing social

I
n December 2016 hundreds of
health care professionals and
consumers came to Philadel-
phia, Pennsylvania, to launch
a nascent but growing national
effort to fundamentally change how the
United States cares for the most vulner-
able and chronically sick Americans.
Spearheaded by Jeffrey Brenner, the
founder of the Camden Coalition of
Healthcare Providers, the gathering rep-
resented the first health care industry-
wide discussion on best strategies for
treating people who, for a variety of rea-
sons including mental health and socio-
economic challenges, end up in the hos-
isolation, said Christina Milano, a fam-
ily physician and an associate professor
at Oregon Health and Science Uni-
versity.
Social Determinants Of Health
At their core, the models rely on recent
research demonstrating that far more

394 Health Affai rs March 2 017 3 6:3 Photograph by April Saul/Camden Coalition
than medical care determines health.
Studies have shown that genetics influ-
ences about 20 percent of health and
medical intervention another 20 per-
cent, according to the Yale Global Lead-
ership Institute.3 Social, environmental,
and behavioral factors can affect as
much as 60 percent of health.
There is now wide acceptance of the
social determinants of health, said Seth
Berkowitz, an internist at Massachu-
setts General Hospital who led a Decem-
ber 2016 study4 that found that the blood
pressure and cholesterol level of many of
his patients improved if they were direct-
ed to and made use of social services
supports. But no one has figured out
yet how best to address [these social de-
terminants], he said.
At this time, many versions of an inte-
grated care model are being tested
throughout the US health care system.5
In one pilot, an insurer is calling cus-
tomers, asking if they need help with
social services and, if so, linking them
to someone who can help. Some pro-
viders are testing whether expanding
resources in their primary care practices
to connect patients to social services
makes a difference.
Hospitals are analyzing whether the
creation of a specific clinic for super-
utilizers reduces overuse of the system;
other hospitals are focused on improv-
ing the discharge and transition process
to home. Still other hospitals are mea-
suring whether expanding their ED
teams to include social workers and be-
havioral health specialists and to help
with housing is effective. Some health
systems have built outpatient teams
with community organizations to see
patients at home. Most of the efforts
have been in place for a decade or less,
and evidence of which scenario works
best is sparse.
I think that we will need twenty to
thirty models targeted at subsets of pa-
tients, based on evidence so that we can
train staff and design workflows to help
these different patients, said Brenner.
Right now, though, we dont have the
ability to do thatto say, if you deploy
this model you can expect that outcome.
We dont have the data and understand-
ing of the population yet, unlike, if we
have a patient with heart disease, we
have many evidence-based approaches
that I can pull off the shelf.
The most successful strategies have
relied extensively on building connec-
tions to local community organizations
that understand the needs of their resi-
dents, said Melinda Abrams, head of the
Commonwealth Funds health care de-
livery reform program.
I think what is going to be found is
that you have to choose a model based
on how you define your population,
said Abrams, whose organization in
December 2016, published The Play-
book, an extensive analysis6 of what
is known about the evidence connected
to super-utilizer models. The propor-
tion of proven outcomes is tiny, but what
is there is promising.
Early Promise
Health leaders repeatedly mentioned
two systems work as aspirational:
Brenners Camden Coalition and the
Southcentral Foundations Nuka System
based in Anchorage, Alaska. After a lot
of work and time, both have produced
some data showing that intensive out-
reach and long-term engagement in
the local community can lead to better
health outcomes and a reduction in ED
use and hospital admissions.
Brenner, a primary care physician,
built the Camden Coalition by piecing
together support between hospitals
and community organizations. Through
grants from foundations, hospital sys-
tems, the state, and the federal govern-
ment, he has built a team of ninety-five
people, including nurse practitioners,
medical assistants, health coaches, and
social workers. Members of the team
visit peoples homes to try to keep them
out of the hospital.
The coalition also has data specialists
who monitor electronic health record
(EHR) information from four local hos-
pitals, and they have begun to gather
information from police departments
and schools to try to predict where
health problems might arise in the fu-
ture. Currently, the coalition is one of
three organizations that are managing
Medicaid accountable care organization
pilots in New Jersey.
Among its first thirty-six super-
utilizer patients, the Camden Coalitions
efforts cut ED visits by 41 percent and
hospital bills in half within the first year
of its intervention launch in 2007, ac-
cording to a 2010 study published in
March 2 017
Perspectives in Health Information Man-
agement.7
More recent data on Camdens impact
isnt available because the organization
is participating in a randomized control
trial of its work. The study, conducted by
the Abdul Latif Jameel Poverty Action
Lab,8 is expected to yield results by the
end of 2018.
Health policy leaders hope the results
will provide more clarity on which strat-
Downloaded from http://content.healthaffairs.org/ by Health Affairs on March 7, 2017 by HW Team
egies are the most effective with super-
utilizers and how to scale the work for
other communities.
Dr. Brenners [latest] study will
hopefully be a beacon of light for all of
us, said Rebecca Ramsay, director of
community care at CareOregon, a non-
profit Medicaid health plan.
In January 2017 Brenner announced
he would be leaving the coalition to join
the health insurer UnitedHealthcare as
senior vice president of integrated
health and human services. There, he
will be running a new business unit de-
veloping new models of care for pa-
tients. UnitedHealthcare also said it
will invest $15 million in the Camden
Coalition.
Meanwhile, the Southcentral Founda-
tion, a primary care provider for 65,000
people10,000 of whom are located in
fifty-five small remote Alaskan villages
is one of the oldest models of care in the
United States that combines medical
and community services.
The foundation has its roots in com-
munity leadership because the regions
Alaska Native economic development
entity owns the organization. Unhappy
with services provided by the Indian
Health Service (IHS), tribal leaders in
1998 exercised their right under the In-
dian Self-Determination and Education
Assistance Act of 1975 to take control of
their health services delivery. Ultimate-
ly, the leaders gave the regions IHS-
funded primary care, pediatric, and ob-
stetric practices to Southcentral. In 1999
tribal leaders asked Southcentral to also
comanage the Alaska Native Medical
Center, a 150-bed hospital that serves
the states 148,000 Native Americans.
During the following decade, South-
central completely transformed its sys-
tem to create one of the most integrated
primary care practices in the country. It
also seamlessly included dozens of com-
munity services into its care plans for
3 6:3 H e a lt h A f fai r s 395
 Entry Point
people and its governance structure, so
that its customer-owners would feel
like Southcentral was like a family and
would have a say in their care.
We dont use the term patient be-
cause we want to emphasize that people
own their bodies, and they are the ones
that know what they need physically,
said Katherine Gottlieb, Southcentrals
president and CEO. They are walking in
tandem, in a relationship with experts,
which is us the providers, and we have
shared responsibility.
Between 2000 and 2015, ED visits
dropped 45 percent, and hospital admis-
sions fell 53 percent.9 Annual health
spending on customers, which includes
medical services, drugs, dental, optom-
etry, and audiology services is about
$8,000 annually, according to Doug
Eby, Southcentrals vice president of
medical services. In comparison, Medic-
aid spent $9,474 per beneficiary in
Alaska in fiscal year 2011, according to
the Henry J. Kaiser Family Foundation.10
Eby cautioned that as a comparison,
Medicaids figure doesnt include
drugs, dental, optometry, and audiology
services.
We are heavy on personnel costs
about double the cost of humans for pri-
mary care, said Eby. But we do way less
labs, x-rays, drugs, and specialist visits,
so we end up with lower total health
care costs.
Southcentral has multiple primary
care teams, each responsible for about
1,100 customers and a rural village or
two. Each team includes a doctor, nurse
case manager, a medical assistant, and
pharmacist. The team members sit near
one another and share responsibilities.
Doctors focus on the most complex
cases, while nurses handle more routine
care.
The foundation expanded its capacity
by building new care facilities on land it
owns in downtown Anchorage. All of the
primary care teams are located in one
building. Dentists, optometrists, audiol-
ogists, behavioral health specialists,
home health providers, dietitians, phys-
ical therapists, pain management spe-
cialists, midwives, and health coaches
all work in other buildings near the pri-
mary care center. Dozens of community
support program meetings take place
in Southcentrals buildingseverything
from domestic violence support to living
396 Health A ffairs M a r c h 20 1 7
At their core, the models
rely on recent research
demonstrating that far
agencies, disconnected from health.
more than medical care
determines health.
well with HIV.
Undergirding the providers work is
an EHR system that enables Southcen-
trals leaders to analyze its customers
health data and determine whether pro-
viders are meeting Healthcare Effective-
ness Data and Information Set bench-
marks and track customer-owners who
might be using the system excessively.
In 1999 Southcentral and the Alaska
Native Tribal Health Consortium, a non-
profit that provides hospital and special-
ty care, agreed to jointly manage the
Alaska Native Medical Center, located
near Southcentrals medical offices.
Through the comanagement agree-
ment, Southcentral and the Alaska Na-
tive Medical Center receive funding
from Medicare, Medicaid, private insur-
ance, and donations. Other funding is
derived from contracts with the IHS, the
Department of Veterans Affairs, and fed-
erally qualified community health cen-
ters. The integrated Southcentral and
Alaska Native Medical Center staff are
paid a salary through the comanage-
ment agreement.9
Part of what really distinguishes
[Southcentral] is its sense of deference
to the Native community and its willing-
ness to go beyond the traditional bound-
aries of care and health benefits, said
Donald Berwick, former head of the Cen-
ters for Medicare and Medicaid Services
(CMS) during the Barack Obama admin-
istration. Can this be done elsewhere?
Yes, and it should be.
Investing In Social Services
Now, nearly two decades since the earli-
est integrated care models launched, a
handful of larger entitiesincluding
about a dozen stateshave begun their
own experiments. Many are working on
using some elements of the Camden and
Southcentral models, such as expanding
primary care teams and fortifying rela-
tionships with community outreach
groups to retool their Medicaid pro-
grams. Their work could serve to accel-
36 : 3
erate health system efforts to provide
more social services to people.
Traditionally, social services have
been administered through separate
Health systems and insurers, therefore,
dont have billing mechanisms for food,
housing, and transportation. Medicaid
and Medicare leaders have also been re-
luctant to shift money from medical ser-
vices to non-medical supports.
Downloaded from http://content.healthaffairs.org/ by Health Affairs on March 7, 2017 by HW Team
The Affordable Care Act (ACA), how-
ever, gave Medicare and Medicaid more
leeway for testing new models, and in
2016 CMS announced it would be doling
out as much as $157 million to health
care systems in 201711 to pilot the best
ways to address peoples social needs.
Whether the repeal of the ACA, expected
under President Donald Trump, will be
an end to the initiative is uncertain.
In 2013 the National Governors Asso-
ciation convened a complex care popu-
lation initiative12 to try and help states
better assess and manage super-utilizers
using Medicaid services. Governors
from ten statesAlaska, Colorado, Con-
necticut, Kentucky, Michigan, New
Mexico, Rhode Island, West Virginia,
Wisconsin, and Wyomingand one ter-
ritory, Puerto Rico, joined the effort.
Wisconsins experience shows how
hard and time-consuming it is to actual-
ly implement such an approach. The
state decided to focus on reducing
unnecessary ED visits among its
Milwaukee-area Medicaid beneficiaries.
Beginning in 2013, the state began
convening meetings with community
groups, more than a dozen Medicaid
managed care plans, and health systems
to build a consensus on how to identify
its highest-needs patients, how to inte-
grate teams, how to pay for the services,
and how to keep providers accountable
for care. After developing an initial plan
in 2015, providers, insurers, and state
leaders decided that the states efforts
should be more comprehensive than
focusing on super-utilizers. The state
doesnt expect to fully launch its com-
plex care management program until
2018.
We have been working on this for
four years, and it feels like its been a
snails pace, but I think its been a great
success in that we are still moving in the
same direction and we are getting major
changes off the ground, said Rebecca
McAtee, director of the Bureau of
Enrollment Policy and Systems at the
Wisconsin Department of Health
Services.
McAtee noted that among the chal-
lenging aspects of the states work is
changing the culture of the current
health system. Traditionally, insurers,
providers, and social workers arent
used to working together, and it has
taken a lot of time to shift peoples
Oregons Ramsay was part of a group
already working to change the structure
of its primary care teams at Portland
clinics. Changes included adding behav-
ioral health support to some of its
clinics.
CareOregon received an innovation
award from CMS to add a community
outreach component because it became
clear that for really complex patients, we
couldnt expect that all their needs
social services supports, and alerting
the primary care team when there is a
problem. Adding that health resilience
component led to a 22 percent drop in
ED visits and 28 percent increase in pri-
mary care use, saving CareOregon about
$1.6 million between September 2012
and January 2015.14 Throughout Ore-
gon, CCOs have reduced Medicaid costs.
Between 2012 and 2014 there was a 7 per-
cent decline statewide in hospital use.13

Downloaded from http://content.healthaffairs.org/ by Health Affairs on March 7, 2017 by HW Team

thinking about their roles.
Oregon began its efforts before the
NGA initiative and is farther along. In
2012 the state overhauled its Medicaid
delivery system and enrolled most ben-
eficiaries into one of sixteen coordinat-
ed care organizations (CCOs)each was
a kind of accountable care organiza-
tion.13 CareOregon is a plan in one of
those CCOs. Inspired by the Camden
Coalition and Southcentral, Care-
would be taken care of in the clinic, said
Ramsay.
CareOregon built relationships with
community groups and hired trained so-
cial workers, peer leaders with experi-
ence in addiction, health coaches, and
behavioral health specialists, called
health resilience advisers. Outreach
staff act like patients family members,
joining them for doctors appointments,
monitoring their health, getting them
The thing with all these models is
they cant be sustained if patients dont
gradate to needing less care, said
Ramsay. And the only way to do that is
to build a community of support around
them, and that is something that we are
still working on.
Bara Vaida (bara.vaida@gmail.com) is an
independent journalist in Washington, D.C.

NOTES
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M a r ch 2 0 1 7 36:3 Health Affa irs 397