Americans’ dissatisfaction with our healthcare system has reached a tipping point. Payers, providers, and plan members all are demanding changes that will deliver greater value. This outcry is encouraging innovative care management services to take new approaches to impact clinical outcomes, cost-efficiency and member satisfaction—the goals of healthcare’s Triple Aim.
There are many causes for dissatisfaction, from a disjointed delivery system to misaligned incentives. But one important area has been the historical focus on specific conditions or diseases. While the population suffers—or has the potential to suffer—from a wide range of conditions, most initiatives have historically centered around the core five conditions of coronary artery disease, chronic obstructive pulmonary disease, diabetes, heart failure, and asthma.
While these conditions remain serious and prevalent, they’ve received a disproportionate amount of focus. Members who were unfortunate enough to have other serious conditions such as chronic kidney disease or Crohn’s disease haven’t received the same level of attention. This could contribute to the fact that while the U.S. spends the most money per capita for medical care, it ranks nearly 40th in population health outcomes and risk factors, according to the World Health Organization.
In short, the nation isn’t doing enough to improve health due to a focus that’s traditionally been too narrow. And tradition, especially in the “first, do no harm” world of medicine, is often a hard habit to break. But break it we must. As fee-for-service rapidly transforms into value-based care, the industry must improve member engagement and outcomes by using targeted care management interventions that help deliver bottom-line results across a broader spectrum of the population.
So how can care management play a pivotal role in the paradigm shift to value-based care—and quickly? Here are five ways:
1. A deeper data dive drives impactability
Leading-edge care management services have learned that it’s time to focus not just on conditions, but on those members for whom services are most likely to have the greatest impact.
This must start with a much more comprehensive look at today’s wealth of real-time datusing sources well beyond retrospective claims or pharmacy data to determine impactability and build the foundation for effective, personalized interventions. Lab, biometric, electronic data feeds such as ADT (admission, discharge, transfer), and non-traditional consumer data are examples of those sources of information that can be used to create a more complete view of each member.
Significant improvements in data analytics and information system interoperability now enable “big data” to transform how payers and providers can look at the complex factors impacting each member’s health. Using these advanced tools, the ways to most effectively target impactable members and approach their opportunities for optimal health are becoming much more apparent, efficient, and effective.
Admittedly, the more data you gather in this process, the more you realize that some of it is spotty or imperfect. That’s no excuse to pass on the insights you can gain from a much larger data pool. Carefully examined, the data drives a deeper understanding of each member’s situation. So when there’s engagement with the right member, the care manager is much better prepared to deliver a series of interventions that are most likely to have the greatest impact.
Data about members and their health status is constantly changing; thus, this data must be constantly updated and evaluated to uncover increasing risk indicators. Advanced software systems can use this inflow of updated data to dynamically prioritize each care manager’s work queue, and direct the care manager on which member to engage with next. This type of automated functionality prioritizes members on an ongoing basis so that care managers can reach out promptly and intervene when it matters the most.