Whole Health - What Medicaid Gets Right

Political debates aside, if you spend a lot of time listening to consumers talk about healthcare in the U.S. today, you can’t miss the fact that they feel stranded and sometimes betrayed by a system that impacts their economic well being and which they struggle to make work for them. Even when they have a strong relationship with one or more doctors, they need a lot more help than they get trying to piece together what’s available and how to make it work for their own personal and familial situation. You can see this in online forums where people post questions and answers, you can see it in the emergence of virtual communities where consumers self-organize around a topic, disease or condition, you can hear it in focus groups and man-on-the-street interviews, or in the stories you’re likely to hear from family, friends or neighbors.

If you’ve ever participated in a GoFundMe campaign, a hugely popular fundraising platform, there’s a 1 in 3 chance you were trying to help someone cover their medical bills. The challenge to survive medical bills seems to cut across most income brackets and other demographics, as does the difficulty in extracting commensurate value from doctor visits and medical treatments billed. People have a lot of trouble applying what they learn in a doctor’s office to the reality of their day to day life: how to make it to the pharmacy before it closes; how to plan your work day when you’re not sure how long you’ll be in the waiting room at the clinic; whether to follow the advice the nurse gave you, the info on the pill bottle or the pharmacist; what to do about your weight; how to get enough sleep; whether your mood swings are a side effect or a medical issue requiring attention; etc. etc. etc. Multiply that trouble by X when you are doing the same for a parent, child or spouse or partner. Cost and benefit seldom seem to meet in the middle.

Interestingly, one of the bigger exceptions in our system today may be Medicaid. “Whole person care” and “social determinants of health” refer to practices and beliefs active among professionals serving health consumers covered by Medicaid, where income, housing status, nutrition and social, behavioral and medical needs are increasingly taken into account in the treatment of patients. Payment models that are based on outcomes and the quality, not quantity, of medical services help achieve this shift in focus (called “valued-based benefits,” this model is also being deployed by providers serving large employers that pay for their employees’ care). On top of medical guidance, there’s recognition that you can’t combat disease on an empty refrigerator, or refrigerate certain medications without one, and that it’s hard to follow doctors’ orders without a roof over your head. Attention is paid to community resources, your social situation, and transportation. This is admirable, and for all the problems in Medicaid, providers serving other segments of the ‘market’ would do well to adopt a similar mindset. While Medicaid patients must shoulder many burdens connected with their level of income, the reality is they are getting more value from their healthcare, and there’s something to be learned from the reasons for that.

When consumers with most other forms of coverage seek a “holistic” approach, the terrain looks a bit different. Unless you have a condition like cancer, diabetes or heart disease, for which payors and providers are more likely to deploy coordinated “care teams,” you are likely to have to piece together the disparate specialists and practitioners who can help you tackle your health issues. The range of medical professionals you may need to consult are typically not well connected with each other, or when they are, not necessarily committed to coordinating with each other in your best interests. If you are lucky enough to work for a very large employer with rich, customized benefits, especially an employer who pays for employee medical treatments directly (as opposed to paying premiums to an insurer who pays the provider), you may have more “concierge” style services and options available, but individuals working for smaller businesses or buying coverage on their own shoulder the biggest burden…and there are millions of them across the country badly in need of similar help.

In good news, there are more and more medical groups and services trying to tackle those problems head-on; ditto for health insurers keen to cover them. Some examples: Iora Health, OneMedical, Heal and Tia.