A Primer on Managed Care: Multiple Chronic Conditions
to food, must be considered before providers can expect people to eat healthily and exercise. In a specific situation, such as transitioning from hospital to home after a case of pneumonia, the needs are more limited. These may be solved via 30-day interventions. These may be more clinical, but social interventions also are needed, such as transportation to follow-up appoint- ments, and to pick up medications. In some cases, the needs can be determined as medi- cally necessary, with some possibility of payment fromMedicare and ongoing support through Medicaid waiver programs. The impacts of policy shift Since the 2010 passage of the Patient Protec- tion and Affordable Care Act (ACA), we have seen a shift in policies that defines how care is provided. There has been increased attention Figure 2. Moderate Functional Impairment Associated with High Medical Costs
Figure 1. Life Expectancy Has Changed Dramatically
Source: National Center for Health Statistics–National Vital Statistics Service Reports, 2010.
limitations, and the shifting payment environ- ment, the healthcare sector and community- based organizations (CBO) have begun partnering to integrate care and more effectively address the social determinants of health and functional limi- tations. CBOs for decades have been addressing social determinants of health: they know first- hand the value of meeting the person where they are, and addressing all of their needs. The impacts of social determinants of health There is now a greater understanding for how social determinants of health impact a person’s health, function, and quality of life. Social deter- minants include social and economic status, health, education level, and the community in which a person lives, and are realized as access to affordable housing, transportation, services to support daily needs, access to healthcare, and residing in a safe and accessible environment (Office of Disease Prevention and Health Pro motion, 2018). Older adults’ healthcare needs can be ongoing and-or time-limited. In both cases, a healthcare intervention, or a response to those needs, often requires a mix of medical and social interven- tions. It has been accepted practice that before a healthcare organization can address a person’s chronic conditions, it must address his or her immediate and ongoing needs. Basic needs, such as paying for rent or utilities and having access
Source: The SCAN Foundation, 2018.
to value-based purchasing, especially in the hospital setting (Centers for Medicare & Med- icaid Services [CMS], and Medicare Learning Network, 2017). There has been a move toward services integration through the Financial Align- ment Initiative, which is focused on dual eligible beneficiaries, who have both Medicare and Med- icaid (CMS, 2018a). And new approaches to care delivery are being tested through entities such as Accountable Care Organizations (ACO) (CMS, 2018b) for Medicare Fee-for-Service.
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