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Providers increasingly are sharing with payers the financial
risks associated with patient populations. Beyond specific treatments, this
model requires them to focus on the entire continuum of care for their patients.
As risk has shifted, providers have found that an effective way to manage risk
is via care management programs that target patients who are likely to be high-volume
users of healthcare services.
In a series of case studies published by the Commonwealth
Fund in 2013, effective care management of chronic conditions such as asthma
and heart failure and a program targeting a Medicare-Medicaid dual-eligible
population resulted in significantly lower hospitalization rates. Average time
between hospital encounters increased for those enrolled in the asthma program,
while heart failure patients and dual-eligibles reduced 30-day hospital
readmissions by 46 percent and 21 percent, respectively.a
Successfully developing and utilizing care management
programs requires providers to think both big and small. They must develop a
sound population health strategy while also having effective care coordination
and communication with patients on a one-to-one basis.
“When you start taking on risk or a shared-savings
arrangement, you start to think about a population health strategy, and that
requires a different set of tools,” says Vanessa Pratomo, MD, medical director
for ACO quality improvement and chronic illness management at Montefiore Health
System in the Bronx, N.Y. “It requires not just providing that direct clinical
care, but also looking at the group of patients you are servicing and trying to
understand who is at high risk—who do I think is going to be really sick?—so I
can get ahead of that need and provide this person with the services that can
keep them healthy.”
According to Clemens Hong, medical director of community
health improvement at the Los Angeles County Department of Health Services,
care management programs typically target a relatively small subset of a
healthcare organization’s patient base: those with complex chronic conditions.
These complex care management programs appear promising, but many have not
shown definitive results.
“High-risk care management allows you to provide, in a very
tailored way, high-quality care to a subset of your patients who have complex
sets of needs,” Hong says. “You tend to see improved quality of care and
improved experience for those individuals who are perhaps your sickest and most
vulnerable. You may see reduced utilization of emergency departments and
hospitals, but it’s harder to return the money you invest in the program.”
Although reported financial results appear mixed, Hong
thinks “the problem often is not in the concept, but in how the concept was
Common implementation errors include not adequately
leveraging internal data and the claims data of payers in the organization’s network,
and as a result not accurately identifying the cohort of patients most likely
to be high-volume users of services. But Hong points out that selecting which
patients to actively manage is not simply an exercise in data analytics.
The most effective programs, he notes, also consider
qualitative approaches—information that physicians can provide based on their
knowledge of individual patients. Such observations may include a patient’s
temperament, his readiness for treatment, and his ability to follow treatment
Hong thus recommends a hybrid approach to patient selection
for care management, one that combines quantitative evaluation of patient data
with qualitative information based on firsthand knowledge about patients from
their primary care provider.
“Data is critically important, but it doesn't provide you
with all the information you need,” Hong says. “Once you have generated a list
from the data, you put those lists of patients in front of the doctors and ask
them to choose, based on the structure of the program and their knowledge of
the patients, which ones they think are most likely to benefit.”
A major challenge to implementing care management is the
deep-rooted influence of fee-for-service at all levels of health care. “If you
think about the average physician, a patient is scheduled, then comes to see
you,” says David Wennberg, MD, former CEO of Northern New England Accountable
Care Collaborative and currently chief science officer at Quartet Health, a New
York-based startup that uses advanced analytics and clinically guided
technology to improve the integration of behavioral and physical health care.
“What providers don’t have is proactive population approaches to managing patients
at risk. One reason is they are accustomed to transactional activity only. My advice is that they should be as concerned
about the patients they aren’t seeing as those who are in their office.”
Michael Hunt, DO, interim president and CEO of St. Vincent’s
Health Partners, the first URAC-accredited integrated health network in the
country, says the Bridgeport, Conn.-based physician-hospital organization effectively
codified this broader view of patient care by requiring physician practices participating
in the network to be certified as patient-centered medical homes.
“Our strength is that we designed our model to enhance and
support the physician who takes care of the patient,” Hunt says. “We put the
focus on the primary care provider, so they can be the captain of the
therapeutic plan for their patients.”
To ensure the primary care physicians stay informed and
engaged in managing the health of their patient panels, St. Vincent’s care
coordinators have a clinical background and meet at least monthly with the
physicians and care teams. The purpose of these meetings is to present
actionable data on patients while also building trust.
“It is a collaborative relationship between the care
coordinators and the providers,” Hunt says. “We expect them over time to get to
the point where the physicians and their office staff view our coordinators as
a part of their care team.”
Although St. Vincent’s spends considerable resources to keep
primary care physicians informed and engaged, the physicians are expected to
play a central role in managing the health of their patient populations. This philosophy
includes a care management model that comprises all the tenets of a patient-centered
medical home. “We are asking them to be responsible for patients in a way they
have never been held responsible,” Hunt says. “When the patient is discharged
from the hospital, the hospital team 'owns' that patient until the patient is in bed at the
skilled nursing facility. When the patient moves back home or back to the hospital,
they own that patient until they move to the next level of care.”
Gaining access to information on all the care that patients
receive is a significant benefit of care management. As Wennberg notes, even in
smaller markets in the Northeast that feature a single, dominant health
network, between 25 percent and 50 percent of care is delivered outside the
network. So developing data systems and processes and having access to payers’
claims data—then providing the relevant data to care teams—enhances the quality
of care delivered and reduces overutilization of services.
“If you think of it from a risk standpoint, which is moving
away from a transactional payment to some kind of performance-based payment, having
people not go immediately to the emergency room or not self-referring to
specialists is really important,” Wennberg says. “And while a primary care
provider can help encourage that, it is my opinion that they can’t do that
alone. They need true team-based care to do that, and part of that team is the
care management component.”
Chris Anderson is a freelance
writer and editor who covers payers, new care models, healthcare IT, and
Interviewed for this
article: Vanessa Pratomo, MD,
medical director for ACO quality improvement and chronic illness management,
Montefiore Health System, Bronx, N.Y.; Clemens
Hong, medical director, community health improvement, Los Angeles County
Department of Health Services; David
Wennberg, chief science officer, Quartet Health; Michael Hunt, DO, interim
president and CEO, St. Vincent’s Health Partners, Bridgeport, Conn.
a. McCarthy, D., Cohen, A., and Bihrle Johnson, M., “Gaining
Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions
Among Chronically Ill and Vulnerable Patients,” The Commonwealth Fund, January
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ICD-10: Managing Performance
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Yuma Regional Medical Center case study
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