Big Picture

As the CEO of Colorado Access, a not-for-profit Medicare/Medicaid plan, Hall believes by looking at the big picture, one can find critical division points that make a difference. On one hand, the plan's big picture is the total member population, and the critical points are the neediest members. But sometimes the big picture is an individual member's socioeconomic situation, and the critical point is as simple as a bed to sleep in.

Instead, Colorado Access has built up its intensive care management team (pictured above) to solve health issues as well as life issues that complicate care solutions. Each month, 1,000 members are stratified with a predictive modeler, the Chronic Illness and Disability Payment System (a diagnostic classification system that Medicaid programs use to make health-based capitated payments), claims and any health status information on record. Increasingly, the plan is leveraging integrated lab and pharmacy data for prioritizing purposes as well. About 400 to 500 people will qualify for and opt into the intensive care management each month.

More than 20 intensive care managers-usually nurses and social workers-go out to the home environments and assess critical points for improvement that would positively impact the members' health status or treatment compliance. One care manager found that a woman with severe back pain had only a single pair of high-heeled shoes to wear every day and no bed to sleep in. A pair of sneakers and a bed brought a significant return on investment, not just in healthcare costs, but in quality of life, too.

While the intensive care management services enhance people's lives, there's a business case for them as well. Tracking a specific group of people receiving the services during 2004, Colorado Access found that: