Integrating Social and Clinical Services into a Total Cost of Care Model
Advancing Primary Care
October 9, 2013
WebsiteSEE GRANT OUTCOMES
Some of New York’s most vulnerable patients present both the highest needs and costs to the health care system. Many of these patients have multiple chronic illnesses, including mental health conditions, and limited social supports.
Unfortunately, lack of coordination or communication among providers causes many of these patients to fall through the cracks. Recent efforts are designed to break down traditional silos and provide patients with a seamless spectrum of services that meet the entirety of their needs. For these efforts to succeed, it is also necessary to change payment systems to create the proper incentives for care integration and to discourage unnecessary and costly utilization such as hospitalizations or emergency room visits. NYSHealth awarded Maimonides Medical Center (Maimonides) a grant to develop an all-encompassing total-cost-of-care reimbursement model.
Under this grant, Maimonides designed a payment model that built a global, risk-bearing payment plan. In addition to combining medical care, mental health services, and care management into one lump sum, Maimonides included a comprehensive set of social services that influence health care utilization, such as drug treatment, housing supports, job training, criminal justice, and domestic violence services. Maimonides conducted a social service analysis of needs, costs, and impact; created a proposal for how these services and costs should be wrapped into a payment model; and produced a method for distributing bundled reimbursement across all participating providers. The resulting proposal for a comprehensive benefits package and payment amount was used for negotiations with government payers and individual insurance plans. This project built on a series of steps taken by Maimonides—which has an estimated 43,000 patients with serious mental illness in its service area—and a broad coalition of providers in Brooklyn to improve the delivery and financing of care for patients with serious mental illness.