We don’t mean social dating, so don’t get too excited. We are referring to field care management, those Population Health Management (PHM) services delivered by care managers face-to-face in person with consumers. Is this the most effective use of limited healthcare resources? You say, yes; a number of studies demonstrate that care management nurses embedded in hospitals results in reduced readmission rates. So, why question a proven model?
A quick review of care management history prompts us to ask this question. Care Management began as a public health intervention in the early 1900s, with current form taking shape in the 1970s for Medicare and Medicaid programs. The commercial application of care management began in earnest in the 1980’s in the insurance industry, nurses making home visits (“field case management”) to ensure disability patients had effective care plans in place. As these payer-led field models grew, it soon became obvious that this was not a financially sustainable model. The cost of covering broad geographies was prohibitive—too many miles, too much drive time between stops. Telephonic call centers grew in response. Telephonic case management programs, whether conducted by a health plan or an external third-party vendor, lead to new telephonic triage and disease management services. By the mid-1990s, the telephonic care management industry was alive and well, touching more patients at lower costs.
The pendulum swung as rising healthcare costs demanded stronger results from care management programs, in particular within the constrained cost structure of state Medicaid programs. If a nurse who never laid eyes on the patient or the provider can deliver moderately-improved outcomes, then what could potentially be achieved if that nurse actually met face-to-face with the patient, their caregivers, and providers?
In the late 2000’s, the care management industry experienced an enormous swing from centralized call centers to re-establishing a degree of field (face-to-face) delivery modalities. Nurses have moved their call center workstations to instead embed in provider practices, hospitals, and communities. Field models are inherently more expensive to deliver due to the geographic limitations and increased patient engagement time. To boost the bottom line, care management models continued to more quickly evolve from registered nurse to licensed and unlicensed social workers, as well as to lay-person community health workers. The staffing mix has historically been heavily dependent on the line of business being served (Commercial, Medicaid, Medicare).
Have we hit equilibrium? We don’t think so.
Let’s avoid another pendulum shift—such shifts are disruptive and not always in a good way. The bandwagon has taken payers and HCOs down the path of feeling pressure to prove that their field model has delivered better results, to demonstrate value against the extra that it cost. We don’t doubt that many of the outcomes are quite strong. We’re simply asking valid questions:
- How much of this is marketing hype?
- What is the right balance of care management (CM) delivery modalities to deliver optimal results at lowest cost?
- How do payers and providers define often overlapping care management responsibilities and staffing models?
It’s time for honest analyses of existing payer and HCO CM programs as more providers take on risk and invest in building new care management models from the ground up.
There are several enabling requirements needed to ensure PHM delivers not just right consumer, right time, right intervention, but also right location of intervention (phone vs office appointment vs home setting).
- Transparent program ROI evaluations by both payers and advanced HCOs across blended populations (Commercial, Medicare, Medicaid) that include location of CM intervention and cost of delivery
- Warehousing and distribution of outcomes data that includes location of intervention, injected into CM workflows
- Predictive analytics at a consumer level and care pathways to inform HCO CM teams of the optimal deployment of interventions, by CM staff role type, and by location of intervention
What is truly the most judicious mix of clinical vs non-clinical and telephonic vs field CM staff to deliver the optimal results for a broad and varied population? HCOs and payers are hungry to know how to best allocate scarce resources. We recognize we are 5+ years as an industry from having this answer. We need to move now in that direction in order to see it to fruition.
Let’s try to get it right this fourth time around.
what determined your decision to use the term consumers in place of the word patients …. while the definition of consumer is a person who purchases goods and services for personal use, its synonyms purchaser, buyer, customer, shopper, user and end user do not accurately reflect the healthcare market …. a patient is defined as a person receiving or registered to receive medical treatment… in traditional medicare the term might apply correctly since people covered by traditional medicare have the power to considered a purchaser or shopper …. people covered by private insurance plans however are quite restricted in their ability to choose … the insurance company determines people will be able to choose from … the insurance company negotiates with a funder to determine who the covered person may seek treatment from when they are a patient … the choice of consumer as a term for persons seeking medical treatment is a “political” term chosen by advocates of certain types insurance plans who want to portray the persons being covered as responsible for costs and deflecting attention from funders and insurance companies whose efforts have made little impact on the healthcare cost curve …
We use the term “consumer” as opposed to “patient” as a reflection of the fact that even those with high-acuity or chronic conditions spend the majority of their lives outside the healthcare system where they receive medical treatment. For good or ill, Chilmark Research also sees the market increasingly shifting to the types of plans that you refer to, which do require participants to shop for the types of coverage they receive as well as the types of treatments they seek — including wellness- and lifestyle-oriented treatments that may not be covered by insurance but nonetheless contribute to improved health and well-being.