The focus on “whole person” care coordination for consumers with complex support needs has pushed managers of traditional specialty organizations to add new expertise to their teams. The reason is simple. For the “superutilizer” populations – consumers who typically have multiple chronic conditions and significant social support needs – best practice has moved from narrow, disease-specific expertise to the ability to coordinate consumer services across the continuum of their needs (see The Path To Building A Consumer-Centric Link Between Hospitals & The Community and Social Services Meets Health Care – Advice For Health Plans & Provider Organizations).
Where I’ve seen the greatest expansion of care coordination focus is in screening and monitoring of diabetes and cardiovascular health in consumers with schizophrenia. The focus has been driven by the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures specific to this population (see A Few More Drops In The Performance Measurement Bucket). But the opioid epidemic may make the management of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) equally important to payers.
The numbers are troubling. Nearly 50% of consumers living with HIV/AIDS report current or past histories of drug or alcohol disorders (see Substance Abuse Treatment In Persons With HIV/AIDS: Challenges In Managing Triple Diagnosis) and the current rate of HIV seropositivity of injection drug users in the U.S. is approaching 60% – up from 30% just five years before (see Combating The Twin Epidemics Of HIV/AIDS And Drug Addiction Opportunities For Progress And Gaps In Scale). In a recent presentation about New York health homes (see Medicaid Health Homes & HIV Care Overview), for Medicaid recipients who are HIV positive, 72% have co-occurring substance use disorders, 50% have severe mental illness, 42% have asthma, and 18% have diabetes.
The recent outbreak of HIV in rural Indiana due to intravenous abuse of prescription opioid painkiller Opana illustrates this connection (see Opioid Epidemic Sparks HIV Outbreak In Tiny Indiana Town and Drug-Fueled Indiana HIV Outbreak Was ‘Preventable’). Over the last 14 months, the state-reported cases of HIV in Scott County, Indiana have risen from 30 to 190, with more than 80% co-infected with HCV (see An Indiana Town Recovering From 190 HIV Cases). In January 2015, the Indiana State Department of Health and the Centers for Disease Control and Prevention (CDC) began an investigation (see Indiana HIV Outbreak Offers Lessons About Containing Local Outbreaks And Need For Harm Reduction) that found as of August 2015 (when there were 170 identified cases):
More than half (55%) of the newly diagnosed individuals were men, all were non-Hispanic white and the median age was 32 years. Among those who were diagnosed with HIV, about 40% reported sharing needles as their only risk factor, 1% reported only sexual risk, another 40% reported both sharing needles and sexual risk, and nearly 20% had unknown risk factors. Almost all newly diagnosed people (96%) reported injection drug use.
This rapid and unprecedented increase in HIV cases has strained the state system’s ability to respond and brought to the forefront the obvious and necessary question – how do we put a system in place for a scenario that many have called “avoidable”? In the short term, Indiana Governor Mike Pence approved a temporary needle exchange program (prior to the outbreak, needle exchange was illegal in Indiana – see Indiana Looks To Canadian Doctors For Help With HIV Outbreak).
But while prevention is crucial to eliminating this linkage in the long-term, there is an immediate demand to address the current situation. Indiana health officials set up what has been described as a “one-stop shop” for health care needs where individuals from the community can access multiple services that are reported to include needle exchange, care coordination, and vaccines; as well as services that help individuals obtain official documents, job training, and assistance signing up for Medicaid. And I found the perspective piece that has responded to this particular incident in Indiana, Threading The Needle — How To Stop The HIV Outbreak In Rural Indiana, in The New England Journal of Medicine, telling:
We believe that threading the needle to prevent further HIV outbreaks among substance users requires aggressive implementation of evidence-based practices for HIV prevention…These practices cannot be implemented without resources for expanding HIV screening among substance users… Primary care models that integrate screening for substance use and mental health disorders and testing and treatment for HIV, HCV, and sexually transmitted infections with concomitant provision of opioid-agonist therapy are therefore an urgent priority.
My strategic takeaway from this development is that for organizations that want to “lead” care coordination for the superutilizer population, expertise in HIV and HCV management is essential (see The Unanswered Questions Of Seismic Strategy). While we have yet to see related performance measures in either the NCQA HEDIS or the Centers for Medicare and Medicaid Services STARS programs, I think the market will move faster than these policy bodies. This expertise will become a market differentiator for contracts with health plans – and essential in the performance that is needed to make value-based contracting work.
For more, don’t miss these articles from last month’s issue of OPEN MINDS Management Newsletter, which was focused on the importance of addiction policy and treatment for strategy – Why Do Changes In Addiction Policy, Coverage & Treatment Matter To Your Organization’s Strategy?, A New Era In Addictions: Medication Assisted Treatment, and The Moving Target Of Addiction Treatment: Recent Changes In Policy & Legislation.
And for more on care coordination with the health home model, including working with HIV positive consumers, make sure to join me on June 9 at The 2016 OPEN MINDS Strategy & Innovation Institute for the session, “Are Health Homes Working? The Payer Perspective,” featuring: OPEN MINDS senior associate Sharon Hicks; Alyssa Brown, J.D., Chief, Evaluation, Research, & Data Analytics Division, Planning Administration, Maryland Office of Health Care Financing; Deborah L. Heggie, Ph.D., Corporate Chief Clinical Officer, Magellan Health Services; and Alan Rice, LCSW, Population Health Specialist, VNSNY CHOICE – Select Health HIV SNP.