Clinical Challenges in Caring for the Un- and Underinsured Implications for Health System Reform

1. Clinical Challenges in Caring for the Un- and UnderinsuredImplications for Health System Reform Brent C. Williams, MD, MPH Medical Director, Complex Care Management Program

2. Goals • Among high utilizing, low income un- and under-insured patients: • Clinical conditions • Health system utilization • Features of optimal health care • Challenges and opportunities for health professions education in care of vulnerable populations

3. Patient 1 - LM • 64 y/o female with ESRD on dialysis. • In past 12 months – 13 admissions for hypotension, C. diff colitis, FTT, etc. • Multiple medical problems, somatic complaints, limited adherence. • Limited coping skills or insight, lives with son with DD.

4. Patient 2 - KH • 35 y/o female with Type I DM, CKD, BPD. Hosp 11 times, 13 ER visits in past year for gastroparesis, abdominal pain. • SSI / medical disability. • Limited social support. • Frequently uncooperative, demanding, non-adherent.

5. Patient 3 - KS • 45 y/o with MVA 1985 -> crush injury L foot, chronic pain. Recurrent DVTs, h/o PE. • Homeless, binge drinker • Friendly and articulate, recurrently drops out of contact, often after blood tests show high INR. • No hospitalizations, rare outpt visits.

6. Patient 4 - JL • 52 y/o male with alcohol dependence, polysubstance abuse (cocaine, heroin), alcohol induced psychotic disorder with hallucinations. • Homeless. • Over 1 year – 12 UM ER visits; 1 SJMH admission, all related to EtOH w/d. • H/O 14 jail sentences.

7. Themes – challenging patients • Clinical complexity – 2+ of: • Major psychiatric disorder • Behavioral disorder • Substance abuse disorder • Multiple, severe medical conditions • Limited social support • Limited resources (housing, transportation) • Limited functional capacity

8. Patterns – challenging patients • Multiple sources of care • Fragmentation • Patient behavior can drive the system • Frequent interactions with • Public Mental Health • Substance abuse treatment services • Social services

9. Health Service Utilization • Top 45 BlueCaid pts 2009-2010: • Median $70,000 (range $52 - $200 K) • Total $3.7 million

10. Utilization - averages • 2005-2006: UMHS Cost PMPY ‘Caid HMO $ 7,900 County Insurance $ 6,500 Dual Eligible >65 $ 8,200 Dual Eligible <65 $11,000

12. Patient 5 - BN • 30 year old male with mild chronic low back pain. Unemployed for 6 months, he fears eviction. Discord with girlfriend. On evaluation he demonstrates depression and anxiety but is not suicidal. • He is eligible for county insurance but enrollment is currently closed. • Access to mental health services is • extremely limited.

13. Gaps in health services • Mental health services for moderately ill patients • Medications • Dental services

14. Questions • What are strengths and limitations of primary care practice in caring for complex patients? • What evidence best guides health system design to care for complex patients?

15. Primary Care and Complex Patients • Time-limited visits • Limited assessment capabilities • Limited intervention capacity • Care direction, coordination • Resource / referral management • Behavioral management plan

16. History and Evidence • Interventions to improve care • Disease management • Geriatric Comprehensive Care • Assertive Community Treatment (ACT) • Healthcare for the Homeless • Chronic Care Management (dual eligibles) • New Practice Models • Chronic Care Model • Integrated Mental / Physical Health Care • Advanced Medical Home • Transition Care Planning

17. Key Success Factors: Complex Care • Effective patient enrollment • Comprehensive, accurate clinical assessment • Clear delineation of responsibilities and team membership • Effective care planning and implementation • Real-time communication • Recognition of team members • Timely access to needed information • Skills / experience with behavioral management / substance abuse • Outcomes measurement / feedback to stakeholders

18. UM Complex Care Management Program (CCMP) • Independent unit • 4.5 Social Work / Nurses • 3.0 Patient Care Assistants • 1.0 Director (Nurse) • 0.2 Medical Director • Administratively under Faculty Group Practice (Medical School)

19. CCMP Functions • Callback (ER, Hospital) • Information • Assessment • Transitional Care • Bridge transition from ER/Inpatient to stable care • Complex Care Management • Continuous co-management with PCP

20. PCP PCP Hospital, Emerg Rm PCP PCP CCMP Home Care Shelter CMH

21. Practice Team Primary Care Provider Care Manager PATIENT Practice Nurses Clerks (Protocols)

22. What are the implications in caring for un- and underinsured patients for health system design under global funding?

23. Under broader insurance and global funding… • Most low-income, un- and underinsured patients will: • Have expanded insurance (mental health?) • Have problems that could be managed in a well-functioning Patient Centered Medical Home.

24. Under broader insurance and global funding… • For a significant minority of very expensive patients, however, key challenges will not necessarily be addressed…. • Fragmentation of care across systems • Uncooperative patients • Barriers among medical, mental health, substance abuse treatment services

25. Ideal Design Features of the “New” system • Care management within and across systems • Single care manager • Real-time and aggregate communication across systems • Incentives for patients to remain under care of a limited number of providers. • Merging of cultures across mental health and medical systems.

26. Health Professions Education and the Underserved • UM Medical School has a strong and growing commitment to providing every student with meaningful experience in underserved settings. • Safety net clinics are low capacity teaching settings. • Affects teaching, faculty training, and financial models

27. THANK YOU