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Care Management in an Evolving Healthcare Industry

by Matt Guldin | September 29, 2017

Care management, sometimes referred to as medical management, is often used as an umbrella term spanning a large number of activities. Other times it is one of several terms under another common umbrella term: population health management.

While the terminology may vary, the goals and objectives are the same:

  • Increase the quality, efficiency, and access to care.
  • Minimize avoidable care situations or events.
  • Control or even bend the medical cost curve.
  • Identify opportunities to reduce the cost of care (through different care settings or resource) without impeding quality or outcomes.

‘First generation’ disease management and wellness programs offered by insurers or third-party vendors, which focused heavily on telephonic-based interventions, did not fare well. One executive even announced (prematurely) the ‘death of disease management’ after a November 2011 New England Journal of Medicine article showed very disappointing results with Medicare’s fee-for-service (FFS) disease management pilot programs.

The experience of the Centers for Medicare & Medicaid Services (CMS) stands in contrast to the long-term and continued reliance by private insurers on disease management in commercial and self-insured lines of business. These insurers have learned their own lessons over time:

  • Identify and only target for enrollment members within the population with modifiable risk.
  • Align care management services to the needs of the particular population being served.
  • Identify and deploy appropriate personnel to deliver the necessary services.
  • Integrate with other services, including behavioral health.

Insurers still have their share of challenges with these programs, though:

  • Disease management ROI is achieved in later years; ROIs is often less than 1 in the first year after members signup.
  • Disease management and wellness program ROIs need to consider factors such as work productivity and quality of life, which makes documenting and calculating outcomes challenging for insurers.
  • Member participation and engagement rates are low; annual member turnover can be high.
  • Clinically relevant data is not accessible in a timely fashion.

These ongoing challenges point to the provider/patient relationship taking on a more important role, prompted in large part by the ongoing shift from FFS to value-based care (VBC) by CMS and commercial insurers. The issue now is become that patients, especially recently discharged or high-risk patients, are assigned multiple care coordinators. It is not uncommon for everyone to stumble over each other; there are no clear demarcation lines about who is responsible for the patient at what time. While care coordination is meant to be team-based, it may require some entity to give up some control of the patient — and that can be difficult when dollars are at risk.

It is possible to add another layer of care coordination, usually based within a provider organization, which takes the lead on care coordination and offers all care coordinators assigned to a patient a common care plan. This might help, but it still poses its own challenges:

  • Startup costs are considerable and costly to maintain.
  • A multi-year timeline is necessary for any ROI.
  • Any success undercuts future traditional FFS revenue for providers
  • Care can’t be easily broken down into discreet “reimburseable” units for FFS payments
  • Care doesn’t fit into longstanding clinical workflows.
  • Considerable data support is required.
  • EHRs are physician-centric and require a care coordination module or a solution from another vendor.

And, as Chilmark Researched explored in depth earlier this year, administrative processes around prior authorization and utilization management also need to catch up to the emerging care management dynamics between provider and payers.

Important questions that should be part of any discussion around care management include:

  • What care management responsibilities should be delegated to whom and when?
  • What organizational structures are payers and providers putting in place to address the shifting care management dynamics?
  • What are the early lessons learned from care management collaboration between payers and providers?

These are some of the areas we plan to explore further in the Care Management panel at Convergence on Oct. 5. We are privileged to have Rick Lopez, MD (Atrius Health), Denise Harr, MD (Capital Blue Cross), and Cynthia Kilroy (Cynthia Kilroy Consulting) on the panel. We hope you will join us to explore this how the roles and responsibilities of payers and providers in care management are evolving in the shift from FFS to VBC.

Stay up to the minute.

“As biometric data becomes cheaper and easier to collect through smart sensors, devices, and mobile apps, expect to see more innovations in consumer health.”

-Alicia Vergaras