The NCSL Blog


By Ashley Noble

People with multiple, chronic medical conditions are one of the most expensive populations to treat.

Laura Black, N.P., a nurse practitioner and clinical director at CCA, is part of a mobile team deployed to help patients like Michael O’Connell, whose complex health needs make it difficult to access traditional primary care clinics.In addition to conditions like heart disease, COPD (chronic obstructive pulmonary disease), diabetes, or other conditions, they may suffer from behavioral health conditions. These conditions can be challenging to treat in tandem.

The Centers for Disease Control estimates that “One-in-four Americans has multiple chronic conditions, those that last a year or more and require ongoing medical attention or that limit activities of daily living. That number rises to 3-in-4  Americans aged 65 and older.” People with more than one chronic condition account for 71 percent of all health care spending in the U.S.

The challenges of treating patients with multiple chronic conditions are sometimes exacerbated by the fragmented nature of our health care system, which can make arranging and keeping appointments difficult. Patients may also distrust institutional health care providers, may not comply with prescribed treatments, or have transitory lifestyles that can seriously undermine the effectiveness of any treatment options available.

A case study released by The Commonwealth Fund examines an innovative approach in Massachusetts designed to address the challenges of treating such patients, particularly those who also face other problems such as inadequate housing, lack of transportation and other social needs that affect their health. The program, known as One Care, is a joint demonstration project of MassHealth—Massachusetts’ Medicaid program—and Medicare.

The program focuses on patients who are eligible for both Medicaid and Medicare, but younger than 65 years old. Although Medicare is most often associated with people who are at least 65 years of age, a person under 65 can be eligible for Medicare enrollment if he or she has end-stage renal disease, Lou Gehrig’s disease, or another qualifying disability related to eligibility for federal Social Security Disability Income.

Patients in the One Care demonstration project received care through Medicare Advantage managed care plans and provider networks like the Commonwealth Care Alliance (CCA). CCA assigned teams to patients to integrate their primary care, behavioral health, medical specialist, and social needs. The president and CEO of CCA, Christopher Palmieri, will be a panelist at NCSL’s Fixing Health Care: What’s Next? session at Legislative Summit in Boston on Aug. 8.

In addition to integrating patients’ care, the One Care demonstration program aims to “meet patients where they are,” rather than expecting them to adjust to the preferences of providers. This can mean making multiple attempts at contact before successfully earning a patient’s “buy in” for a treatment strategy.

It can also mean looking beyond a patient’s symptoms to determine what other supports might improve a patient’s health and quality of life. For example, a patient without safe, affordable housing might be connected to programs that can ensure he or she has a place to live. A stable living situation can improve the effectiveness of treatment strategies for the patient’s medical needs.

The One Care program reported a 7.5 percent decrease in hospital admissions and a 6.4 percent decrease in emergency department visits among participants after 12 months of enrollment. The program has not proved to be less expensive than conventional delivery and treatment methods, though CCA “expects to achieve savings in 2017.”

In its first year, enrollees in One Care required a greater-than-expected investment to control complex medical needs and conditions, such as schizophrenia, that had not been adequately addressed under previous care models. CCA and One Care providers are hopeful that long-term health outcomes and cost reductions will improve.

Ashley Noble is a policy specialist in NCSL's Health Program.

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.