Could we organize care differently when it comes to intellectual disabilities? (2/2)

My first post identified a few opportunities for a medical home model to improve care.

(By the way, it’s liberating to step back from the usual political thrust-and-parry. I’ve gotten so angry that I’m having trouble really listening to and learning from other people regarding the deep partisan disagreements in health policy this campaign season. It’s also liberating to read some of the great comments. For example, I also wonder about the future role of independent practitioners who cater to populations with special needs. I fear these practitioners will be squeezed out, as for good reasons and bad our delivery system moves to more complex models of team-oriented care.)

But I wonder what’s realistic to expect here from a broader policy perspective. Policymakers are hoping that novel delivery models will save money. I’m reasonably skeptical of these possibilities. The historical track record of analogous models is certainly mixed. I’m not convinced that reduced expenditure is the right framing, either.

I’m sure there are valuable opportunities to save money by providing more coordinated care, and by eliminating some of the more obvious pathological incentives in fee-for-service care. A health care system accountable for its infection re-admission rates might manage Vincent’s hospitalizations more diligently, and make a greater effort to coordinate the different specialists involved in Vincent’s care.

A different medical care delivery model might also provide more effective support to the staff at Vincent’s group home, who struggle with certain aspects of his wound care (e.g. the fact that he keeps removing his bandages.) In diabetes care and care at federall-qualified health centers, there is some promising evidence that improved care delivery can improve cost-effectiveness of care, though the impact on overall expenditures is more complex

A different medical care delivery model might more effectively monitor wasteful care, and drive a harder  bargain in domains ranging from genetic screening to durable medical equipment and medical imaging. My wife and I had a long conversation regarding whether Vincent would genuinely benefit from his special $600 molded prescription shoe. It’s easy to ponder every aspect of that question without ever considering whether $600 is truly a reasonable price. Right now, few actors in the system have both the demand-side market power and incentive to focus on the price of such things.

Still, it’s a lot easier to see how novel care arrangements would improve quality than it is to see how they would really save money.  Many people living with intellectual disabilities are now grossly under-served. Moreover, their medical care is financed under rather Spartan Medicaid arrangements.

Many people with intellectual disabilities need serious vision, speech and language supports, and dental care. Others would benefit from dermatology of psychiatric assessments. A well-implemented medical home model would presumably address such under-provision of services. These arrangements might improve cost-effectiveness. It’s not at all obvious that such an arrangement can, would, or should seek to reduce overall costs of care.

There’s an awkward political question, too. Suppose an academic medical center assumes responsibility for 10,000 intellectually disabled adults in greater Chicago. That organization would enjoy serious market power in the local marketplace. It would also become the hub of an incredibly powerful political network of both providers and patients which is more likely to advocate for valuable enhanced services than it is to support more disciplined forms of care.

One might address this tendency through some sort of risk-adjusted capitated payment system that gives providers incentives to seek more cost-effective care. This might work. Some of my own research suggested that a managed care plan could reduce ED use among children with special health care needs. It’s a stretch, though, to believe that large amounts could be saved. The uniquely sensitive nature of this population would understandably make policymakers and families quite nervous about any delivery model that might reward reduced delivery of care.

I am also wondering how realistic it is to believe that one could really risk-adjust this population. Patients with intellectual/developmental disabilities comprise a small, complex, and highly-varied population. These patients pose more challenging and less-familiar difficulties than are posed (say) by diabetes patients enrolled in patient-centered medical home arrangements.

Diagnosed and undiagnosed comorbidities are both common among the intellectually disabled. This remains true within more narrowly-defined populations such as fragile X patients. Incentives for “diagnostic upcoding” must also be considered. Vincent  is well-behaved and reasonably healthy. It would still be rather easy to legitimately diagnose him with an autism spectrum or anxiety disorder if this brought greater reimbursement or access to valuable services.

As in many areas, it’s easy to imagine systems that deliver better care, or ones that deliver care that is cheaper. It’s just harder to imagine a care delivery system that accomplishes both of these objectives at once, as the political imperatives of health reform often demand.


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