I’m a longtime fan of “wholistic” healthcare and case management processes, with a “W” as opposed to an “H” for holistic. This approach addresses whole-person care of physical health, behavioral health, and psychosocial circumstances, taking care not to leave any holes in care; it’s an approach that’s even more vital for today’s populations. This approach is also in sync with value-based reimbursement methods.

Due to COVID-19’s rising numbers, especially amid communities and populations most vulnerable to racial and socioeconomic disparities, the Centers for Medicare & Medicaid Services (CMS) is again emphasizing the power of value-based reimbursement. Considering that national health expenditures for 2020 are expected to more than double to over $7 trillion, courtesy of the pandemic, the industry will be even more fixated on high-cost populations and defined strategies to rein in future costs.

COVID-19 outcomes were released by CMS last week. Health disparities and the social determinants of health (SDoH) were front and center in the data. Based on Medicare claims for beneficiaries from Jan. 1 through May 16 of 2020, the data revealed spending of $1.9 billion in fee-for-service payments for 81,227 COVID-19 hospitalizations. Other notable statistics included:

  • Average hospital reimbursement was $23,000.
  • Black beneficiaries accounted for almost four times more hospitalizations than whites, with:
    • Black adults having the highest hospitalization rate among racial and ethnic minority groups: 465 hospitalizations per 100,000, compared to whites, at 123 per 100,000.
    • In comparison, Hispanic beneficiaries had 258 hospitalizations per 100,000, and

Asian beneficiaries had 187 per 100,000.

  • End-stage renal disease patients – individuals with chronic kidney disease undergoing dialysis – had the highest rate of hospitalization among all Medicare beneficiaries: 1,341 hospitalizations per 100,000 beneficiaries.
    • A majority of these persons live with several challenges related to the SDoH, among them food insecurity, transportation challenges, access to healthcare, medication access, and prescription drug costs, health literacy, and of course, major financial challenges.
  • These patients also have chronic comorbidities associated with increased COVID-19 complications and hospitalization, such as diabetes and heart failure, which prompt increased hospital utilization, including increased emergency department visits, admissions, length of stay, and overall resource use.
  • Dual-eligible beneficiaries had the second-highest overall hospitalization rate, at 473 hospitalizations per 100,000 beneficiaries, with:
    • Higher COVID-19 infection rates: 1,406 cases per 100,000 beneficiaries.
    • By comparison, the infection rate for beneficiaries enrolled only in Medicare was 325 cases per 100,000,

CMS is echoing what industry providers, practitioners, and payors have been saying for the past several years: clinicians must have access to a payment structure that accounts for “wholistic” healthcare, addressing pathophysiology, psychopathology, and psychosocial risk factors to improve quality of life for beneficiaries and the financial health of health organizations. 

Today’s Monitor Mondays survey digs deep into the impact of this latest data on the reimbursement for health systems and organizations. You can view the survey results here.

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