The Affordable Care Act (ACA) and expansion of Medi-Cal hold the potential to improve the lives of millions of Californians, especially those with asthma, diabetes, heart disease, depression, and other chronic illnesses. Yet coverage by itself is no guarantee that these patients, who face many daily physical and emotional challenges, will start to receive high-quality care tailored to their needs, since access and cost issues may prevent them from receiving timely care.
Ensuring High-Value Care, one of CHCF’s three new goal areas, is focused on delivering better outcomes and lowering costs for the 5% of the population that accounts for 50% of medical spending. We will be working specifically on the population with untreated mental illness or substance use disorders leading to poor medical outcomes. This population uses emergency services frequently and has difficulty accessing coordinated medical, behavioral, and social services that could stabilize and improve their lives.
The path to improvement won’t be easy. A recent study by the Office of Statewide Health Planning and Development (OSHPD) finds that emergency department (ED) visits are actually up in California since the implementation of the ACA, which was confirmed by a national survey of ED doctors. The OSHPD study found that the increase in the number of ED visits in California among the insured was offset on a nearly one-to-one basis with a decrease in ED visits by uninsured patients. There will likely continue to be pent-up demand, however, unless other access points can be developed to meet the needs of high-use patients, as well as lower-risk patients who experience difficulty accessing other options for primary and urgent care.
The Impact of Behavioral Health
When it comes to complex chronic disease, behavioral health diagnoses are a major driver of high medical spending. For example, 2011 data from California’s Department of Managed Health Care Services showed that, for diabetics, the presence of serious mental illness increased hospital days by 48%, the presence of alcohol or drug use by 112%, and the presence of both diagnoses by 168%.
A new CHCF Almanac report, based on survey data from UCLA’s Center for Health Policy Research, finds that 8% of California adults — 2.2 million people — say they experience serious psychological distress, making it the second most common chronic condition cited after hypertension. Psychological distress is also the most common condition for which respondents say they delay seeking care, whether due to cost, lack of access, or stigma.
The Role of Health Homes
The State of California has a unique opportunity to improve care for patients suffering from complex behavioral and medical conditions through the proposed Health Homes Program. HHP would leverage federal funding to support community-based care management, which helps connect patients to resources in social services (housing, food, legal aid), behavioral health (mental health counseling, addiction treatment), and health care (primary care, medical equipment, medications). Although still in the planning stages in California, it has a successful track record in other states.
HHP presents a real opportunity to pilot new ways of connecting the complicated silos of the delivery system, with the promise of improved outcomes for patients and lowered costs for the system. If successful it will go a long way toward fulfilling the promise of better coverage for chronic disease patients, and could mark a milestone in progress for health care in America.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also cochaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco. It was the first time a local government in the US attempted to provide health care for all of its constituents.
In February 2018, Sandra was appointed by Governor Jerry Brown to the Covered California board of directors. She also serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and on the UC Regents Health Services Committee. Sandra is an assistant clinical professor at the UCSF School of Medicine. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016.
Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.