Miguel is in his mid-fifties. He lives in Camden, NJ, the city once named the Silicon Valley of the East— birthplace of the radio, phonograph, and television— now perennially named one of the poorest and most violent cities in the US. Miguel was born into addiction: his mother sold drugs for a living, and he started using heroin at 11, an addiction that persisted for nearly four decades.  Miguel was unstably housed for several years and was unemployed and socially isolated.

In a nine month period, Miguel’s uncontrolled Hepatitis C, congestive heart failure, and hypertension resulted in 3 emergency visits, 7 inpatient admissions, and 61 days in the hospital, totaling about $112,000.

When a community-based care team from the Camden Coalition of Healthcare Providers met Miguel, they discovered those staggering hospital bills were largely preventable. By coordinating his care and linking him to the appropriate social supports, they were able to decrease his health care costs by $100,000. Today Miguel is thriving. He has not used heroin for 4 years. He has permanent housing through our Housing First program. He works at the local wellness center, providing support to those currently experiencing addiction. He is writing his autobiography.

There are patients like Miguel all over the country— in cities and rural areas, struggling with what we call complex health and social needs: a combination of chronic illness, mental health and substance abuse issues, often exacerbated by a lack of housing, income, and social support that result in overuse of expensive emergency health care resources. Five percent of patients in the US make up 50 percent of health care costs.

The good news is that there is a growing coalition of hospitals, insurance companies, nonprofits, and state governments that are starting to embrace the innovative programs that target patients with complex health and social needs. So what does better care really look like? How can we ensure that our nation’s next wave of health care reform delivers better care at lower costs?

We have some ideas. Here are five basic principles for how to improve our health care system, especially for those vulnerable populations with complex health and social needs.

  1. Integrate care, integrate funding. The true drivers of poor health and high costs are often unmet needs such as homelessness, addiction, and mental illness. Yet the way we pay separately for these services too often prevents coordination of health care and social services. Places like Hennepin County (Minneapolis) have integrated their health care and social services, resulting in lower costs and better care. Integrated funding must become the norm to effectively improve health.
  2. Innovate locally. America leads the world in medical innovation.  But what is needed now, more than ever, is innovation in how care itself is delivered at the local level. Regulatory flexibility and financial support for innovation are necessary to design and scale the delivery models that efficiently serve our most expensive and vulnerable neighbors.
  3. Build a smarter healthcare system. Remaking our delivery system requires good data to understand both where the waste, duplication, and inefficiencies are located and where the bright spots of what’s working exist. Despite significant investments in health IT, most electronic health record systems don’t talk to each other. States like Maryland have created health information exchanges that enable health systems to identify and deploy resources to the most expensive patients in their community at critical moments. Smart investments in regional and statewide data infrastructure will eliminate waste, reduce fragmentation, support coordination and promote innovation.
  4. Focus on the mental health, addiction, and pain epidemic that is killing our children, family members, neighbors, co-workers, and vets. Mental health, addiction, and pain are foundational diseases that exacerbate the human and financial costs of other chronic conditions. In 2015, the US opioid epidemic killed more than 33,000 people. Yet, evidence-based medication assisted therapy like buprenorphine can treat addiction in primary care just like any other chronic illness. We need to get rid of the barriers that have hindered the swift expansion of cost-effective treatment models, just as we would in any other epidemic.
  5. Give all Americans the opportunity to access the right care at the right time and at the right place. Without access to community-based treatment, people delay care and end up in the most inefficient and expensive care settings, including emergency rooms, inpatient care, long-term care, and ultimately the criminal justice systems. Especially for those facing complex health and social needs, the most efficient system is one that provides access to the right care in the right place at the right time: coordinated care, in their community, before they are in crisis.

Imagine what our system would gain if it were designed to effectively treat the patients like Miguel with the highest needs and highest costs. How much money spent on avoidable hospital stays could be reinvested into communities and into evidence based strategies that work? How many lives could be saved? How many families and communities could be strengthened? Better care at lower cost is possible, but only if we can transform our systems so that they work for us when we need them most.