By Monica E. Oss, Chief Executive Officer, OPEN MINDS
A plethora of policy changes is shaping health and human services towards a focus on whole person care approaches in the context of integrated system. CMS policy has changed, allowing Medicaid health plans to pay for intervention related to social determinants (see ‘State Medicaid Managed Care Plans Can Spend Up To 5% Of Premiums On Social Determinants Of Health’). And many state Medicaid waivers—such as CalAIM in California— have a focus on whole person care (see ‘California’s ‘Whole Person Care’ Medicaid Pilot Program Resulted In Fewer Hospitalizations & Emergency Room Visits’).
But questions remain in taking advantage of these new opportunities. How do we bring the concept of whole person care into reality in practice? And how much does it cost to expand primary care to a whole person approach? The answer, according to one of the first estimates for primary care practices (see’ Estimated Costs of Intervening in Health-Related Social Needs Detected in Primary Care’) is $60 per member, per month (pmpm).
Unpacking the Literature I read the analysis with interest. The cost estimate is based on a practice simulation model. The researchers simulated the cost of annual screening and referral for social needs within a primary care practice, including the costs of training and deployment of a standardized screening instrument; education and counseling for consumers concerning their rights and social service options; and closed loop, electronically facilitated referrals. And, for consumers ineligible or not enrolled in existing federally funded programs, the simulation included the costs of providing additional non-federally funded, evidence-based interventions. The model used assumptions of social needs prevalence for moderate to severe food insecurity (17.5%), severe housing insecurity (0.9%), transportation insecurity (2.8%), and eligibility for community-based care coordination (12.7%).
The model assumed similar social needs prevalence among FQHC practices and non-FQHC practices in high poverty areas and dissimilar among practice types in lower poverty areas. Among consumers attributed to FQHCs: 31.9%, 1.1% 3.4%, and 12.6%, respectively, were estimated as have food insecurity, housing insecurity, transportation insecurity, and community-based care coordination needs. Among non-FQHC practices in lower-poverty areas, the estimates included 4.3%, 0.2%, 2.2%, and 9.4%, respectively, for food insecurity, housing insecurity, transportation insecurity, and community-based care coordination needs.
Despite whether the cost of the simulated model—$60 pmpm—is exactly right or even realistic from the payer perspective, the analysis raises important questions for taking whole person care to scale. What do payers and health plans expect from primary care and specialty care coordination organizations when it comes to addressing the social service needs of consumers? And how do payers and health plans develop capitation rates for primary care and health and medical homes that are adjusted by the social support needs of the population?
I’m sure there will be more on this topic in the months ahead. In the meantime, stay tuned to ONEcare Population Health Academy for more news and insights in the field of whole person care and integrated systems.