Susan Harkema

Physical medicine has had many years' head start over behavioral medicine in adopting quality performance measures and data-driven quality improvement (QI), as well as value-based payment arrangements and incentives. The longstanding, divided nature of how mental and physical health is organized, paid for, and regulated has had an untoward effect on behavioral health. It's resulted in fragmented and inequitable care that's less accessible than physical healthcare and produces more varied efficacy of outcomes.

There are several ways that providers, like family medicine and primary care, health systems, and value-based care groups, are leveraging innovative payment arrangements and technologies to provide behavioral health support and treatment. These approaches and programs hold promise to reduce the parity between physical and behavioral health but also support providers in preventing and addressing the needs of their senior adult patients.

The combination of a burgeoning senior adult population and an increased prevalence of behavioral health conditions—encompassing mental health and substance use disorders—creates greater risks to elder health and wellness. It also produces an unsustainable burden on Medicare and provider organizations.

During the pandemic, remote patient monitoring (RPM) produced mounting evidence that it provides a cost-effective method to monitor and support care for many chronic illnesses. Physicians are beginning to realize the many benefits that enable them to follow the patient's status and make necessary changes that deliver better condition management. In a landscape of value-based and accountable outcomes, RPM can help prevent exacerbations and costly inpatient admissions. For patients, the benefits of RPM include improved ongoing care and monitoring, the sense of peace that comes with oversight, and the convenience and cost savings from avoiding unnecessary care, as well as the time and cost of travel. Studies reveal how patients and physicians view the value and promise of RPM. These validations are pivotal drivers for adoption, further government and payer reimbursement, and value-based care inclusion.

Retail has entered the healthcare space, and there's no turning back. What does this mean for health systems? Healthcare innovation includes retail and provider organizations that have an opportunity to lead their strategy or risk falling behind. Several population, healthcare, and retail trends are converging. Health systems can investigate these shifts using SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis to determine if partnering with retail aligns with and accelerates their care, operational, and business objectives.

Primary and specialty care providers want to extend care beyond the clinic, but it’s tough to do alone. Enter the community pharmacist uniquely positioned to support a successful remote patient (aka physiological) monitoring (RPM) service. By collaborating with pharmacists, providers can enhance patient access to RPM services, deliver enhanced support and follow-up, as well as address the complex drug therapy management needs of specific patient populations like those living in rural communities, advanced in age, historically marginalized, or experiencing inadequate care access. Implementing an RPM program with a pharmacist aligns with The Joint Commission’s Pharmacist Patient Care Process. Community pharmacists have access to patients throughout their care journey and can collect, assess, and analyze patient data while providing education, engagement, and continuity between patient and physician.

RTI Health Advance was engaged by a prominent military managed care contractor to support their transformation in providing healthcare to a large number of service members and their families. With a new contract to begin in 2024, this military health vendor wanted to evolve their traditional approach and services to prioritize performance outcomes, expanded services, interoperability, and beneficiary experience while realizing the Military Health System's (MHS) Quadruple Aim. This case study reviews the challenges our client faced and its goals for the engagement. The approach taken by RTI Health Advance provided detailed recommendations the client could implement as part of a comprehensive, whole health framework. The framework, and its prioritized areas, are underpinned by a quality improvement model.

Health disparities caused by health inequities cost the US billions each year; the National Vital Statistics Reports estimates that disparity-related direct medical care expenses cost $230 billion annually. Actuarial analysis of high-cost diseases puts that estimate at $320 billion a year. Conversely, providing equitable care—or ensuring that all individuals receive the tools and resources they need to achieve health and well-being, regardless of gender, ethnicity, geography, or socioeconomic status—could save the US upwards of $1 trillion per year. Payers, providers, and self-insured employers face a moral imperative to improve health equity for members, patients, and employees. Beyond civic and societal benefits, these parties can also realize additional value and market strength through sound business investment in health equity initiatives.

Previously, we published a primer on social determinants of health (SDoH), social risk, and health equity indices, providing an evaluation framework to uncover critical characteristics when considering an index. This article offers a deeper look into 5 prominent indices, providing an overview that can be used to facilitate comparisons while offering guidance on the SDoH use cases that may be appropriate for each index.

Despite increasing blood pressure awareness and control, more than 30% of adults with hypertension are unaware, and nearly 50% of diagnosed hypertension is uncontrolled. With the cost of diagnosed hypertension exceeding $50 billion annually, traditional office-based hypertension treatment hasn’t proven effective or efficient enough. High blood pressure (HBP) also remains poorly controlled at the population level. Remote patient monitoring (RPM) for hypertension is a proven methodology that physicians can use to predict and prevent cardiac incidents related to HBP. Through clinical trials, RPM has realized improved outcomes by enabling accurate, early BP detection and decreasing all-cause mortality rates and hospitalizations. And as part of Medicare reimbursement for RPM, primary care physicians and cardiologists can more effectively assess, treat, and monitor existing hypertension.

Amidst more people living in poverty and widening income inequity in the US and globally, we explore the current state of income instability, the effect of income on health, and walk through the major programs that are having a positive impact across numerous social risk factors, particularly health. While poverty is a recognized contributor to higher mortality and disease, income inequality in the US has grown dramatically. As upper-income levels have increased considerably, middle-income has decreased significantly, and lower-income levels have nominally reduced. Figure 1 shows the gaps in income among US populations over time.

Nearly half of all American adults have multiple chronic conditions, accounting for $1.1 trillion in healthcare costs annually. Additionally, two-thirds of Medicare beneficiaries have two or more chronic conditions. Yet, in recent surveys, 85% of physicians felt they didn’t have adequate time to provide needed care to these patients, and over 90% wanted help to ensure that patients with multiple chronic conditions could adhere to their care plans.

Following the Healthy People 2030 model, this article series focuses on the 6 aspects of social determinants of health, including food insecurity, economic stability, neighborhood and the physical environment, education, community, social support, and healthcare access. First, we'll discuss the impact of food insecurity on adult health and well-being, share national and regional programs, and highlight the programs and models that are making a positive impact. Defining and quantifying the challenge of food insecurity While food insecurity doesn't always cause hunger, it indicates a lack of access to adequate, affordable, healthy food. The US Department of Agriculture (USDA) defines food insecurity as "a household-level economic and social condition of limited or uncertain access to adequate food." In 2021, more than 38 million Americans were food insecure.

Comprehensive care coordination provides professional support to patients, helping them navigate healthcare and manage their health better. To that end, research on SMART goals has demonstrated its value toward patients creating healthier habits and achieving better health outcomes. When combined with Motivational Interviewing techniques, SMART goals establish clear, internally-motivating, and measurable goals that align with what’s most important to each individual.

In 2020, the US Federal Government finalized the “Transparency in Coverage” Rule, requiring health insurers, group health plans, as well as self-funded clients, to provide cost-sharing data to consumers via machine-readable files (MRF). Beginning July 1, 2022, required machine-readable files have provided pricing data for covered items and services based on in-network negotiated payment rates and historical out-of-network allowed amounts.

Digital therapeutics (DTx), including prescription digital therapeutics, have demonstrated clinical efficacy, but economic evaluation is critical to payer reimbursement and provider adoption. Assessing and showing the cost-effectiveness and value of DTx requires a broader approach beyond the standard model used for pharmaceuticals and medical devices. Let's look at the challenges to evaluating economic impact and techniques that have been used and published to date along with our guidance on choosing the best data and assessment models to demonstrate value.

Over 30 years ago, the Americans with Disabilities Act (ADA) changed the trajectory for millions of Americans living with disability. The intervening decades have unfurled material changes, such as: curb cuts, disability parking and seating in public facilities, bus lifts, more accessible telecommunications, and laws to support fair employment practices. Recognizing these changes, though, many Americans with disabilities continue to face deep, longstanding health inequities, including barriers to care, lower quality of care, and disparate health outcomes. With a population of 61 million adults and 3 million children, representing 28% of Americans, persons with disabilities comprise the largest subpopulation in the US, reflecting all races and ethnicities. At a time when health equity conversations,requirements, and plans are ramping up positive change, persons living with physical, behavioral, or sensory disabilities should be included in the movement for more equitable healthcare.

A recent New England Journal of Medicine article acknowledges that a lack of alignment across CMS quality programs confuses and challenges clinicians and health plans. The organization has set forth 20-plus quality programs in its 20-year history of creating transparent quality performance information, driving better accountability in the interest of improving US healthcare. Yet the lack of alignment creates a “tension between measuring all important aspects of quality and reducing measure proliferation." To address the misalignment, CMS has proposed a building block approach called Universal Foundation. The new model focuses on quality measures that will create “more parsimonious sets of measures" to focus provider attention and drive quality improvement and care transformation. The foundation will apply to many CMS quality rating and value-based care programs.

Section 1115 demonstration waivers provide states an avenue to test new approaches in Medicaid. Although the waiver program has been available since 1982, states are ramping up Section 1115 authority to address enrollees' health-related social needs (HRSN). This overview article explains Section 1115 waivers and recent developments to promote coverage, access to and quality of care, improve health outcomes, reduce health disparities, and create long-term, more cost-effective alternatives or supplements to traditional medical services. We will also profile how waivers have been used to address social needs and provide insight into what states, payers, managed care organizations, and provider-partners can do to maximize their impact through these innovative payment and delivery models.

A recent New England Journal of Medicine article acknowledges that a lack of alignment across CMS quality programs confuses and challenges clinicians and health plans. The organization has set forth 20-plus quality programs in its 20-year history of creating transparent quality performance information, driving better accountability in the interest of improving US healthcare. Yet the lack of alignment creates a “tension between measuring all important aspects of quality and reducing measure proliferation." To address the misalignment, CMS has proposed a building block approach called Universal Foundation. The new model focuses on quality measures that will create “more parsimonious sets of measures" to focus provider attention and drive quality improvement and care transformation. The foundation will apply to many CMS quality rating and value-based care programs.