AUSTIN, Texas—As health insurers face increasing pressure to bring down costs, their focus naturally turns to working with high utilizers of healthcare. But given how much of one’s health is determined by social factors, this has proven to be no easy task.
During this year’s AHIP Institute & Expo, health plan leaders shared some of the innovative ways their organizations are tackling the steep challenge of helping members live healthier lives. Here’s a look at what they shared:
Behind some of the major social factors that affect health, from lack of transportation to food insecurity, is one issue, explained John Lovelace, president of UMPC for You and president of government programs and individual Advantage products.
“It is poverty that drives most of the social determinants of health,” he said.
To take on an issue closely tied to poverty—homelessness—UPMC created a program with the dual aim of connecting individuals to permanent housing and coordinating their care. Its goal is to help get individuals who have no reliable residence, and often lots of unplanned healthcare utilization, into a more stable situation, Lovelace said.
To achieve that, UPMC makes a deal with these individuals: If they agree to go to a specific primary care practice and work with a care manager, the organization will connect them with permanent supportive housing.
The project, Lovelace said, “did exactly what it was supposed to do” over its seven years of existence: It significantly reduced emergency department visits, improved medication adherence and increased primary care visits. What’s more, 85% of members involved were successfully housed.
Blue Shield of California
Simply put, these type of interventions are “the most clinically effective, the less costly and the least invasive out there,” said Angie Kalousek Ebrahimi, Blue Shield’s senior program manager of wellness market solutions.
Blue Shield’s suite of “lifestyle medicine” programs, collectively called “Wellvolution,” goes beyond just fitness-tracking apps. It includes programs like QuitNet, a large social tobacco cessation network; Solera, a diabetes prevention network that targets people in the at-risk stage; and UnDo It, an intensive program that aims (and has succeeded) at reversing coronary artery disease.
To encourage uptake of these programs, the insurer relies on principles of behavioral science, Ebrahimi explained. For example, given people’s bias toward the status quo, many of the programs take advantage of that inertia by having members opt out, rather than in.
And because social norms are “a very powerful nudge”—meaning people will adopt lifestyle behaviors they see around them—Blue Shield created a social network around all of its wellness programs. The insurer also allows non-members to join in so members can have their support networks participate.
Though it’s a fully integrated health system, Kaiser Permanente faces a similar problem to nearly all healthcare organizations: A small share of its patients account for a large share of healthcare costs.
And better clinical care isn’t the way to solve it, said Nirav Shah, the senior vice president and chief operating officer for clinical operations for Kaiser Permanente’s Southern California region.
“They’re getting all that our traditional healthcare can provide—they’re getting the best hospital care, specialists, care managers,” he said. “And yet we’re failing them. We’re not addressing their total health.”
So Kaiser conducted a randomized trial in which it called 5,000 of these high utilizers and asked questions like, “How can we help you?” and “What do you need?”
Their answers revealed a variety of needs, including caregiver support, financial help, access to healthy meals and reliable transportation. Once needs were identified, the health system did everything in its power to address them—then later called the members back to ask if the intervention helped.
Kaiser is still evaluating results of the pilot, so the initiative is really just getting started. But one thing has become clear, Shah said: “We have to redefine what counts as healthcare.”