July 24, 2012

Three Imperatives for Nonprofits Seeking to Participate in Health Care Reform

Bridgespan partner Daniel Stid sees a major role for the nation’s human service nonprofits in health care reform, as these organizations have long served on the frontlines supporting the individuals who put the biggest demands on Medicaid. Nonprofits seeking to rise to this momentous occasion must respond to three imperatives: patient-centered care, partnerships, and performance.

By: Daniel Stid

My last post highlighted the critical role human service nonprofits have to play in supporting the implementation of health care reform. Now that the Supreme Court has given states the option of expanding their Medicaid programs (or not), realizing the goal of universal coverage will ultimately depend on making Medicaid much more affordable. This will require bringing costs down for the five percent of Medicaid patients driving 54-percent of the costs in the system. These high-cost patients are much more likely to be suffering from mental illness and/or substance abuse, both of which increase the complexity and costs of chronic health problems. Hence the potentially major role for the nation's human service nonprofits, which have long served on the frontlines supporting these individuals in their struggles. Nonprofits seeking to rise to this momentous occasion must respond to three imperatives, encapsulated below as three "P's" patient-centered care, partnerships, and performance.

1. Patient-centered care: This imperative requires major shifts in mind-sets. First, nonprofits that have traditionally seen the people they serve as "clients" or "beneficiaries" to whom they are providing social services need to see them instead as patients, i.e. people who are suffering and to whom they are providing health care and guidance so they can live healthier lives. If nonprofit leaders and staff don't see themselves and the people they are helping in this way, then health care payors, providers, and the patients themselves most certainly won't. Second, the siloed nature of their government funding creates a tendency for human service nonprofits to focus on what they do, i.e., counseling and recovery programs, instead of what they are trying to accomplish for the people they serve, such as helping them live healthier lives. Patients, not programs, need to be at the center of nonprofits' understanding of their work and why they are undertaking it. Third—and most fundamentally—these patients have a right and need to participate in and make decisions about their care. As Don Berwick, then president of the Institute for Healthcare Improvement defined it in a 2008 article entitled "What ‘Patient-Centered' Should Mean: Confessions of an Extremist," this entails "the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one's person, circumstances, and relationships in health care." It can be especially challenging to provide truly patient-centered care to people coping with mental illness and substance abuse, but can nonprofits help them achieve the steep improvements in their behavioral health and corresponding decreases in their health care costs that are needed without engaging them in this way?

2. Partners: Human service nonprofits are notoriously apt to go it alone instead of joining forces with other organizations, even when it is in their economic interests to do so. But they will need partners to play a major role in health care reform. Fortunately, the Accountable Care Organization (ACO) framework established by the Affordable Care Act enables a new form of partnership among provider organizations prepared to take on collective responsibility for the health of a specific group of people. Indeed, the National Council for Community Behavioral Health, which sees the rise of ACOs as a tipping point for behavioral health, observed in a recent report that, "if these providers work together to help improve the health of their patients, provide better care, and reduce costs while achieving identified outcomes, the ACO will be able to share in the savings generated by their good work…[ACOs are] the vehicle for changing the incentives in the U.S. healthcare system so that we move from a sick care system (the money only starts flowing after you get sick) to a true healthcare system." The report concludes with some wise counsel: Behavioral health nonprofits should not wait to be asked to join an ACO. They need to actively seek out a place in one that works for them—or, if need be, to take the initiative and help create one in which they can make substantive contributions.

3. Performance: Nonprofits' ability to join and benefit from ACO partnerships and similar arrangements will hinge on their ability to positively impact the health of patients they are supporting in systems of care, to improve the results for patients over time, and to document that they are doing so. Demonstrating improved outcomes will be the currency of the realm in the new landscape. In order to garner the requisite currency, nonprofits will need to move beyond the conventional use of measurement in the social sector—i.e., to report to external funders and stakeholders—and use it instead as a tool for fostering reflection, learning, and ongoing improvement. At the same time that they are improving results for the patients they are supporting, however, nonprofits will also need to be reducing the costs of delivering those results. Within the social sector there is a growing backlash against the notion of doing "more with less," with some charging that this simply leads to doing "less with less." However, the productivity imperative is here to stay. As Don Berwick recently pointed out in a keynote address to IHI last December, after having returned battled-scarred from running Medicare and Medicaid for the Obama Administration, "for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of health care—and, harder, returning that money to other uses—while improving patient experience. ‘Value' improvement won't be enough. It will take cost reduction to capture the flag."

Please let me know what other imperatives for nonprofits seeking to play a role in health care reform you would add to this list (don't worry – your suggestions don't need to begin with "P"!).

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