Bridging margin and mission: Making the value case for complex care

Building the complex care field Care management & redesign Funding & financing

By Lauran Hardin MSN, CNL, FNAP, FAAN, and Mark Humowiecki, JD

For those of us working in the field of complex care, COVID-19 has only underlined the urgency of attending to the needs of this population, and opinions and policy are changing as a result. More community and health system partners are coming to the table and looking for guidance for building a complex care ecosystem and more funding, both at the state and federal level, is becoming available for this type of holistic, health- and socially determined care. In addition, there is the collective desire to redress the pre-existing health inequities that the pandemic has both exacerbated and laid bare.

But talking mission and ethics and what’s right is not always enough to convince the country’s healthcare systems to connect with each other and work with nonprofits and community organizations across sectors to serve complex populations. What is crucial to convincing them to join in these efforts is taking a financially savvy and articulate approach to elucidating the benefits of doing so — that is, to present the positive financial impact that caring for individuals with complex health and social needs can bring to the equation. Equally important is presenting the argument in language that those in the C-suite leading these organizations can understand and can get behind.

In interviews with over 100 health system leaders, payers, community-based organizations, and innovators, we explored what makes a compelling value case that can motivate investment in complex care. Here are some of the approaches we heard that can effectively change the minds of those who hold the purse strings, need to turn a profit, and want to do the right thing:

Treat chief financial officers as partners, not gatekeepers

To argue the financial benefits of what we do, it’s crucial to speak to the financial implications of our work. Doing so requires learning a bit of another language, so to speak, as well as a clear understanding of costs of delivery, appropriate dosing of interventions, and their impact on different drivers of cost (including fixed and variable expenses). 

The bottom line: Being fluent in “financial-ese” is necessary to making a strong case for entering the field of complex care.

It’s also crucial to treat hospital systems’ chief financial officers as partners and members of the interprofessional team rather than as gatekeepers. Besides speaking their language, that means understanding their goals and acknowledging that financial incentives will differ depending on the level of value-based payment, like an ACO, an individual’s payer source (Medicaid vs. private insurance), and the impact the program will have on delivering the right care in the right place at the right time.  

To be clear, it’s not that C-suite leaders don’t believe in the mission of helping society’s most vulnerable. We’ve seen for ourselves how motivated they are by that mission, and how much pride they take in the work, especially during COVID-19.  As Gay Landstrom, Senior Vice President and Chief Nursing Officer at Trinity Health in Michigan, said, “We really redoubled our commitment to caring for the poor and vulnerable, and particularly minority populations. [The pandemic] caused us to look deeply and figure out what we are really here for; and if we don’t fulfill that mission, should we even continue?” 

Change is coming

As payment structures shift to more value-based arrangements, the incentives for more organizations to align with local and community-based partners are increasing, and the momentum to take a collaborative approach to treat populations with complex health and social needs is gaining steam. As Emily Brower, Senior Vice President at Trinity Health, told us, “Our experience with COVID has amplified the value of value-based care…including the population health clinical model, the alternative payment models, and true clinical integration among providers.””

California is putting some muscle behind helping these models flourish and make an impact, despite the fact that they may not immediately increase healthcare systems’ revenues in obvious ways. Through its CalAIM initiative, which is set to launch in January 2022, Medi-Cal will pay directly for the services it wants to see, rather than hoping the delivery system will invest in such programs on the promise of savings. Services Medi-Cal will pay for include enhanced care management and certain non-medical services, such as housing supports and medically tailored meals. The state has prioritized populations with very complex health and social needs for this higher level of service, including those who are homeless or at risk of homelessness, adults with complex behavioral health needs, and those who have been frequent users of hospitals and short-term skilled nursing facilities. 

Get savvy with partnerships 

The pandemic accelerated the need to partner across sectors to meet individuals’ health and safety needs, and to respond to social needs like food security and isolation. As leaders now think about the value case for complex care in a post-pandemic world, they’ve identified powerful lessons that came from working together across sectors. One example is how organizations were able to create stronger, integrated systems and realize improved delivery through the sharing of resources and funding streams.  

To make a targeted business case for complex care, it’s important to consider potential partners and how coming together could strengthen your organization’s impact and create financial efficiencies. As Jonathan Weedman, Vice President of Population Health for Care Oregon, put it, “We think about it as, ‘What’s yours, what’s mine, and what’s ours.’” This means designing your intervention in the context of the ecosystem of existing programs, emphasizing what you uniquely provide, and making clear how you can accelerate impact by delivering care together. CommonSpirit is an example of a health system doing this work through shifting community benefit dollars to invest in community collaboratives. New funding like the American Rescue Plan Act is increasing investment in cross-sector approaches to complex populations. As communities learn the power of partnership, new ways are emerging to blend and braid funds across sectors to address the needs of complex populations.

With support from The Commonwealth Fund, lessons from these interviews have been captured in a toolkit entitled “Making the Value Case for Complex Care.”

A more equitable system

All of us have gone into the field of complex care to care for those in our society who too often fall through the cracks. By sharpening our competence in articulating the financial case for what we do, we can begin the systems-level change required to truly shift resources to complex populations in a way that best serves their needs, and thereby advance the cause of health equity in this country.