One provision of the American Health Care Act (AHCA) would allow states to create high risk pools to offer healthcare coverage for individuals with costly or catastrophic conditions who would be difficult to insure otherwise. AHCA allows $25 billion in federal funding over 10 years to support the program.
Critics caution of unsustainable costs for patients as well as taxpayers, while proponents believe separating the patients with higher costs would allow the remaining insurance market to function better. In theory, the average, healthier population could purchase more affordable insurance that is not skewed by the small percentage of people who account for a disproportionate share of costs.
States could potentially include behavioral health patients in high risk pools.
"In some respects, a high risk pool can be a good thing," says Anthony Mele, chief clinical officer for Sovereign Health. "But when we hear about it, we perhaps see it as a way of reducing services. I don't know how it's going to play out in the current iteration, but I've seen it work in a good way that benefits people. I've also seen it used as tool to restrict access to care. Hopefully in this model it will serve the folks who need the services."
Mele says patients with other chronic conditions such as diabetes or heart disease have been included in similar models. In behavioral health, bipolar disorder or major depression might meet the criteria to warrant coverage and care separate from the average population, he says.
In past implementation, the pools aimed to address the cost of insurance coverage. In today's era of comprehensive care, however, improved health management would also need to be considered.
Mele says Sovereign has a measurement-based care model that helps clinicians determine care efficacy for individual patients. Every two weeks, care teams conduct an evaluation of therapies and patient response with an eye for outcomes within the care continuum.
"If we add measurement-based care to the risk pool, it would help us tailor it," Mele says.
He also says a high risk population in behavioral health would need more thorough evaluations from the start.
"The other issue, in addiction treatment especially, is the failure in many cases to do a good upfront assessment," he says. "What happens is that we don't know the cognitive functioning or the emotional functioning of the person who's experienced 10 or 20 years or more of addiction."
Clinicians might be trained to apply dialectical behavioral treatment or motivational interviewing without the assurance that the patient will respond to verbally mediated treatment modalities, he says. Efficacy will become particularly important for high need patient populations.