CCE's and the WalMartization of human services

CCE's and the WalMartization of human services

In the for-profit sector, "Walmartization" has dangerous implications, ranging from the shrinking of the small business sector to my personal hoarding of Pringles variety packs and Jackie Chan DVD collections. However, in the nonprofit sector, the "one-stop shop" approach is gaining momentum as the best way to deliver services to needy populations. The rationale is simple: needy people almost always have more than one "need." Mental illness begets unemployment, which begets homelessness, which begets substance abuse, which begets contraction of disease. Since many people in crisis are unable, or unwilling, to access services at multiple locations, then why not bring the services to them? The odds of somone who is homeless taking an HIV test - or registering for Art Therapy, or applying for job training - is infinitely greater if it's offered in the same building where he/she goes for food and shelter.

This movement to cluster services is engrained in President's Obama's vision for improved health care delivery models. As part of his sweeping Medicaid reform, Obama wants states to issue large, multi-year grants to "Coordinated Care Entities (CCE)," groups of human service agencies - i.e. primary care providers, hospitals, mental health service providers - that will work in synergy to address every aspect of health. Currently, the health care system mostly operates on an expensive and broken “fee-for-service” model, which turns care providers into service islands whose only financial incentive is to provide - and often over-utilize - Medicaid-billable services. Limited communication between providers places a heavy burden on Medicaid recipients, who spend too much traveling from one location to another, often getting contradictory medical advice and repeating unnecessary medical procedures. CCE's will receive a flat fee for all care related to a particular patient and will be held accountable for that person. Streamlined communication - i.e. having a mental health professional in the doctor's office during a wellness check - and a stronger emphasis on long-term care will lessen the need for more expensive medical care, such as visits to the emergency room (for example, Cook County Hospital runs an annual deficit of about $150 million). CCE's place a particular focus on people with mental illnesses, addictions or chronic conditions like diabetes, heart disease, asthma and kidney failure. These people can have three, four, or even five different case managers, depending on how many agencies they utilize. Within a CCE, they will have one who will help them navigate the system.

As Ezra Klein phrased it in a blog post: “The hope is to do nothing less than change the basic business model of American medicine from making money by getting patients to spend more money to making money by saving patients money.”
Illinois is actually ahead of the curve (for once!) in terms of Medicaid reform. The state has passed a law that requires half of the state’s 2.8 million Medicaid recipients to be enrolled in “coordinated care” by 2015. A CCE has already been formed to serve the 40,000 elderly and disabled Medicaid recipients exiting institutionalized care in the wake of the Williams, Colbert, and Ligas class action law suits. A CCE for children with complex needs is slated to launch in 2013. And with 200,000 people in Cook County about to become Medicaid eligible, with another big wave of new enrollees coming in 2014 when Medicaid expansion takes full effect, the demand for these CCE's will be enormous in the coming years.

If CCE's can execute what states are promising - improved long-term health and decreased societal costs - then it could make an immeasurable systemic impact that extends beyond health and taxes.


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