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Five ways care management can shift to value-based care


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.

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.

Next: Determining impactability




2.    Determining impactability

Part of the initial discovery process recognizes that many factors affect impactability. For instance, although a member may have a health situation that can be improved and is willing to be engaged in the process, a combination of clinical, social, environmental, and behavioral issues can be barriers to success, such as a lack of:

· Consistent medication adherence

· Reliable transportation, causing missed doctor or pharmacy visits

· An engaged care support system (family, friends, neighbors)

· A safe living environment

· Positive mental outlook

· Good financial standing, including credit rating

The existence of factors like these doesn’t mean that a member can’t be positively impacted; these are just among the issues that must be taken into consideration to develop an effective, precision-targeted plan.

On the other two ends of the continuum, there may be more limited opportunities to impact health. On one end, members who are already engaged in their health, understand their disease, are conscientiously taking their medications and seeing their provider are already probably doing all they can. Care management is unlikely to have a significant impact.

On the other end of the continuum are members who are so critically ill, such as an end-stage cancer patient receiving optimal care, that few actions are also likely to have much impact. To be effective and efficient, care management programs must be able to identify these members for whom interventions and coaching are unlikely to make a positive difference.

3.    Finding the root cause

The impactability discovery process has as its core a search for the root cause of the member’s health situation.

Once precision analytics enable determination of how to accurately identify and stratify each member based on their impactability, care managers can determine what interventions are most likely to improve outcomes. If the member feels his care is disjoined, his care manager can facilitate coordination between providers or find new ones. If he’s not consistently taking medications, he can be placed on a medication adherence track; this could include prescription delivery or access to transportation to get to the pharmacy, or a digital app to connect him with his care team and support circle to encourage and remind him to take his meds. If it’s due to depression-often a root cause of other health issues-he can be connected to mental health services.

Next: Communication tools




4.    New communications tools, processes improve engagement

Rather than thinking that Big Brother is intruding in their lives by gathering and assessing their data, most members welcome the research and attention that goes into improving their lives and health status. Most find that it adds value to their understanding of what is impacting or has the potential to impact their health, delivered by someone they come to think of as their care management partner.

What also encourages engagement and compliance are the growing number of ways members can choose to have those interactions. It’s no longer just a long, infrequent call they may find as an annoying intrusion into their day. The growing list of communications options include secure texting, email, and even private social networks for the member and his or her authorized support circle.

It’s also been found that the most effective way to engage impactable members is through short pulses. The frequency of these pulsed touch points depends on the member’s health situation. Someone who’s recovering from surgery probably needs more regular contact for a period of time, while members in better health require fewer interactions, though they would benefit from positive reinforcement through occasional contact. This highly personalized approach is how care managers develop trusted relationships which encourage continued engagement.

5.    The path to improved outcomes, savings, and satisfaction

This may all seems pretty intuitive, considering the new data sources and tools available. But relatively few care management services have yet to go this far. They haven’t fully embraced that while you can’t ignore the core five conditions, effective care management must take a step beyond to expand data sources, tools, and processes to ensure the best possible impact for each member, and for the greatest number of members.

The most effective care management services should deliver targeted, effective programs that-with care managers “armed” with a plan developed using the latest, richest, and most trusted data and analytics-can succeed in enabling optimal health, cost-effectiveness, and satisfaction. Triple Aim goals: achieved.


Ron Geraty, MD, is CEO of AxisPoint Health.


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