Two studies published this week in Medical Care Research & Review found that providing integrated medical care and social support services led to increased use of primary care among very low-income adults in Hennepin County, Minn., who were enrolled in a Medicaid accountable care organization (ACO) between 2012 and 2014. Strong primary care relationships, combined with mental health treatment, were linked to improved quality of life among enrollees of the ACO. Researchers from the University of Minnesota School of Public Health and Clinical and Translational Science Institute, Hennepin Healthcare, Hennepin County and the University of Michigan who conducted the study also found the rate of emergency room visits was higher for the Medicaid ACO enrollees compared to non-ACO enrollees in the area, but that the rate declined during the study period.
Claims analysis showed desirable utilization trends over time and among certain populations
One study used Medicaid claims data to compare the use of medical services by Hennepin Health ACO enrollees to non-ACO Medicaid enrollees in the same geographic area. Adjusted results of the claims analysis showed that in the first two years, Hennepin Health enrollees had 11 percent more primary care visits and 52 percent more emergency department (ED) visits. At the same time, looking at changes in time trends of health care use over that same period, enrollees in Hennepin Health had a decrease in both primary care visits and ED visits, an increase in dental visits and a non-significant decrease in hospitalizations while non-ACO enrollees showed an increase in hospitalizations. Subgroup analysis of high utilizers of care showed significantly lower hospitalizations in Hennepin Health than in non-ACO plans.
“Integrated, accountable care under Medicaid expansion led to some desirable utilization trends and subgroup benefits, but it didn’t reduce overall acute use of medical services when compared to other approaches to managed care,” said co-author Nathan Shippee, Ph.D., an assistant professor in the division of health policy and management at the University of Minnesota’s School of Public Health. “However, our findings align with other studies that have shown initially high rates of health care use, especially in the emergency room, among new insurance enrollees in general and particularly among Medicaid enrollees. It’s possible that more initial use of health care services by vulnerable, high-risk individuals like those enrolled in Hennepin Health is predictable, appropriate and may result in better long-term health outcomes.”
Interviews showed ACO enrollees connected to services reported better quality of life
The other study used qualitative interviews to explore which parts of the Hennepin Health ACO’s integrated approach to medical care and social services was associated with changes in enrollees’ quality of life. Researchers conducted semi-structured interviews with 35 primary care-using Hennepin Health ACO members enrolled for two or more years during the study period. Interview topics included the enrollee’s social, behavioral and medical history, experiences seeking health care, and perceptions of health-related quality of life over time. Findings included:
- 66 percent of ACO members interviewed had a diagnosed mental illness
- 40 percent had some degree of unstable or subsidized housing
- 20 percent reported use of shelters or homelessness during the study period
- 60 percent described a strong, trusting relationship with their primary care provider or care team
- 46 percent received consistent mental health care
- 40 percent had frequent documented contact from their extended care team (8-12 contacts per year)
- 49 percent could not recall documented contact from their extended care team
Analysis of the interviews revealed “causal recipes” associated with improved quality of life. In all of these recipes, the key ingredient list included consistent mental health care and a strong bond with the primary care provider and care team. A strong bond was characterized by patients feeling listened to, respected and cared about. Hennepin Health enrollees who described a higher quality of life were those who consistently received services from the clinic-based extended care team supported by the Hennepin Health ACO delivery model. Furthermore, enrollees who remembered interacting with care team members described experiencing them as positive connections who often deepened their trust in the primary care provider.
“Our findings suggest some low-income Medicaid patients appreciate integration of mental health and primary care, and that such integration may increase their trust in the primary care team,” noted Shippee. “This is an under-reported finding in current literature that suggests the need for more research to explore this potential link.”
Research explored unique care model
Very low-income, non-disabled adults without children became eligible for public health insurance in Minnesota for the first time in 2011 when Minnesota expanded its Medicaid program under the Patient Protection and Affordable Care Act. A team of researchers from the University of Minnesota School of Public Health and Clinical and Translational Science Institute, Hennepin Healthcare, Hennepin County and the University of Michigan examined the experiences of the subset of those individuals who enrolled in Hennepin Health, a county-owned health plan that operates as a Medicaid ACO in partnership with Hennepin Healthcare, NorthPoint Health & Wellness Center and Hennepin County.
The Hennepin Health ACO works to coordinate enrollees’ medical care, mental health care and social services, such as housing and nutrition assistance, using an interdisciplinary team approach that spans a defined primary care clinic network and Hennepin County’s health and human services department. The team includes nurse care coordinators, social workers, community health workers and housing navigators who integrate enrollees’ social needs into care planning for their health conditions. The ACO puts the care team where enrollees are, from emergency departments and clinics to homeless shelters and correctional facilities. All members of the care team use a common electronic health record to manage and track enrollees’ progress against care goals.
“Our research team wanted to understand whether this particular approach to integrating medical care, behavioral care and social supports might yield better results for a particularly vulnerable population that had little or no previous exposure to managed health care,” said co-author Katherine D. Vickery, M.D., a family medicine physician and clinical investigator at Hennepin Healthcare. “One of our findings is that Hennepin Health enrollees are more likely than Medicaid expansion enrollees in other area managed care plans to have complex social needs such as homelessness and substance use disorders.”
The studies were supported by the Commonwealth Fund (grant number 20140726) and the National Center for Advancing Translational Sciences of the National Institutes of Health and Minnesota Department of Human Services (grant number UL1TR000114).
Hennepin County & Hennepin Health:
Carolyn Marinan, Chief Public Relations Officer
University of Minnesota:
Katie Ousley, Public Relations Consultant