If you got a couple dozen of the most powerful and influential health care leaders in Montana together in a room, they'd tell you that, overall, spending on health care here could be a lot more efficient.
That's actually exactly what happened Tuesday in Helena.
A group of insurance company and hospital executives, doctors, clinic managers and others involved in Montana healthcare met to brainstorm solutions to problems like this one, described by State Medical Officer Dr. Greg Holzman.
"The most expensive — this is the top one percent of clients within Medicaid — account for 25 percent of the Medicaid budget."
Holzman's saying that just a relatively few people can rack up huge costs if they have very complicated medical problems. And he says it's not just an issue for government-funded healthcare programs like Medicare and Medicaid.
"I think if you talked to most commercial carriers, they would say it's fairly similar for them, too."
The group that met in Helena is a special council on healthcare innovation appointed by Governor Steve Bullock about a year ago. About that time, Montana got a million dollar federal grant to look for ways to streamline healthcare.
One of the big issues they've chosen to tackle is trying to find ways to keep people from needing really expensive medical care. One way to do that is to focus on helping people who have multiple health conditions. Dr. Holzman showed the group a chart of how expensive treatment is for them.
"You take someone with a mental health disorder, and also a physical disorder, you see the costs go up astronomically."
Sometimes, those astronomical costs can be prevented. A project in Billings, for instance, reaches out to homeless alcoholics and offers them both addiction counseling and regular medical care. A result is that those people don't go to local emergency rooms as often.
Before the project started, those emergency room and other healthcare costs added up quickly, says Lenette Kosovich Edgerton, with Rimrock Treatment Center in Billings.
"They came to a cost factor of nearly $115,000 per person per year in services that these folks were actually using."
The idea of better coordinating mental and physical health care is one of the primary areas the healthcare council has decided to focus on, says Jessica Rhoades, the health policy director at the state health department.
"The way our healthcare system is structured right now, sometimes you have to go to one place to get your physical health care needs met, and you have to go to another separate location to get your mental health care needs met, and really you’re all one person," Rhoades says.
"And so the goal is to make sure there’s better coordination across providers, even different kinds of providers; behavioral health providers, mental health providers, substance use providers, so that a team of healthcare professionals can collaborate to improve your health overall," she says.
Trying to get mental and physical health care systems to work better together is a focus of health care reformers nationwide. A big reason it's so hard to do is because there are separate payment systems for mental and physical health care. Changing that could mean disrupting how insurance companies pay doctors, what kinds of services clinics offer, and where patients are sent for treatment.
Talking about how to change that gets into the bureaucratic weeds pretty fast. Anna Whiting Sorrell with the Confederated Salish and Kootenai Tribes' health department tried to bring things back to ground level.
"I've heard a lot about what physicians need, what billers need, what regulators need," said Whiting-Sorrell. "What I’d like to be sure is asked is: What does the patient need? The patient needs to be the focus and the center of whatever model we put in place."
Whiting-Sorell is one of two people on the 23-member council who represent Native American organizations. She wants a greater role for Indians in the council's work, beyond its recognition that health indicators show Native Americans lagging behind whites in may areas, including a life expectancy that's 15 to 20 years shorter. Whiting-Sorell says it's naive to think that if reformers manage to put together a new, more rational and streamlined health care system, that Native Americans will eagerly embrace it.
"When you have been told 'no' for generations: No, you're not going to get care. No, you only get care when your life, limb or sensory is at risk. And no, you don’t get to have aftercare. You don’t get to do follow-up. No, you don’t get rehab. Oh, you had a heart attack and you need cardiac rehab? No.
"And you’ve done that for generations, and you’ve lost your grandparents, and you’ve lost your parent and your children have dropped out of school. How all of the sudden to you expect people are just going to show up?" Whiting-Sorrell asked.
The Governor's Council on Healthcare Innovation has now met twice. It plans to issue a report in March, and continue meeting for another year. Its goals include increasing dialog in Montana on how to get more value for health care spending, to address mental health care and disparities in health status, and to improve health information technology.