ManagedCareSupplement3

A Primer on Managed Care: Multiple Chronic Conditions

The Role of Social Determinants and Why Community-Based Programming Works By Karen D. Lincoln

Social needs often are not met during healthcare visits, but HCBS can fill that gap.

H ealth spending in the United States is pro- jected to rise to $3.5 trillion in 2018, a 5.3 per­ cent increase from 2017. Primary drivers of the increased spending include the aging population and growing prevalence of chronic conditions, which are difficult to treat and responsible for 85 percent of healthcare costs. Three in four Ameri- cans older than age 65 have two or more chronic health conditions, such as diabetes, hypertension, arthritis, or cancer. These individuals may strug- gle to manage their health in ways that allow them to maintain wellness and independence. Despite the increasing costs associated with treating chronic conditions, individuals with chronic illness often do not make significant progress with their health conditions. Nearly one in five Medicare beneficiaries are readmit- ted to the hospital within thirty days of an ini- tial discharge, and many more end up in the emergency department (Brennan, 2014). It is estimated that readmissions for Medicare ben-

eficiaries cost $26 billion a year, of which an estimated $17 billion comes from potentially preventable re-hospitalizations. Findings reported by the University of Wis- consin Population Health Institute indicated that many of the largest drivers of healthcare costs fall outside the clinical care environment (Uni- versity of Wisconsin Population Health Institute, 2014). Only 20 percent of the modifiable variation in health outcomes is due to clinical care, whereas 40 percent is due to social and economic determi- nants, 30 percent to health behaviors, and 10 per­ cent to the physical environment. This report came out just a few years after the Robert Wood Johnson Foundation’s report called Health Care’s Blind Side , which showed that 85 percent of pri- mary care physicians and pediatricians indicated that unmet social needs—e.g., access to nutritious food, reliable transportation, and adequate hous- ing—were leading to worse health for all Ameri- cans (Robert Wood Johnson Foundation, 2011).

abstract Social determinants of health—income, education, social inequality, living conditions, food security, environmental factors, and health behaviors—account for 80 percent of modifiable variations in health outcomes. They are key to improving health outcomes and optimizing healthcare resources. Unmet social needs are not typically detected or addressed by clinicians during healthcare visits; this increases risk of chronic conditions, reduces the ability to manage health conditions, and increases risk for morbidity, mortality, and institutionalization. Home- and community-based services fill the gap left by the healthcare system by addressing these needs. | key words: social determinants of health, commu- nity-based programs, chronic conditions

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