High-touch providers coordinate care for high-cost members

TODAY THERE ARE approximately 75 million Americans with two or more chronic conditions. Often the sickest members of a population, they suffer the most from the disconnect between primary care physicians and specialists, are hospitalized at a far greater rate, and face the highest risk of adverse drug events.

Likewise, their care is comparatively more costly, according to a December 2009 study by the Robert Wood Johnson Foundation. The foundation's Synthesis Project found that total healthcare spending for people with five or more chronic conditions is 17 times higher than for people with none.

"[The medical home] is really a systematic approach to making the healthcare model operate the way it was designed, with primary care as the center of coordination for complex-needs patients," says David Labby, MD, medical director for CareOregon, a plan that began its medical-home strategy in January 2007. "It represents a rethinking of the entire healthcare system's approach from one of silos to one of integration."

For example, Geisinger in Pennsylvania is working more directly with delivery systems on population management, embedding complex-care case management nurses who used to work at the health plan into clinics, according to Dr. Labby.

Approaches that target high-needs members often focus on care coordination and education. One such example is the ambulatory intensive caring unit (A-ICU), which was created by Cambridge, Mass.-based Renaissance Health and Mercer Health and Benefits, through a grant from the California Health Care Foundation. A-ICU fosters frequent, in-person interaction between caregivers and their high-risk patients and has demonstrated a 20% cost savings.

"The goal is to work with patients to optimize their care management: help them develop care plans, identify barriers, follow their progress, and make caregivers accessible when patients have questions," says Rushika Fernandopulle, MD, co-founder of Renaissance, which operates as a healthcare consultancy and an internal medicine practice. "Our approach differs from the usual disease management because it is largely conducted in person, in the doctor's office. That offers a lot of advantages compared with the remote, telephonic model."

Because high-touch models like A-ICU and medical homes require more interaction between patients and providers-far more than the typical 15 minutes of facetime-insurers have begun to develop new strategies to make that possible.

IT support, such as electronic systems that reduce the amount of time doctors spend on paperwork, can free up clinicians for patient interaction. Another strategy involves the emphasis on using non-physician caregivers when appropriate, such as nurse practitioners and physician assistants. Coordination of care remains focused on PCPs, however, both for quality and cost reasons.

"In addition to improving the quality of care, PCPs also play a critical role in moderating the cost of healthcare," says Gus Manocchia, MD, vice president and chief medical officer for Blue Cross Blue Shield of Rhode Island (BCBSRI). "The data shows that in areas where there is more primary care infrastructure versus specialists, the quality of care is better and costs are lower."

Jay Feldstein, DO, corporate chief medical officer for the AmeriHealth Mercy Family of Companies, agrees with that assessment, adding that the insurance industry "is moving toward outcome-based partnerships with providers to improve health outcomes and chronic condition management. There will be continued emphasis on the integration of physical and behavioral health to manage care in a holistic fashion."

As difficult as it is to coordinate care for any individual with multiple conditions, the problem is made even more complex among Medicaid members. According to a 2009 study by the Center for Health Care Strategies, "The Faces of Medicaid III: Refining the Portrait of People with Multiple Chronic Conditions," the elderly and adults with disabilities make up only 25% of Medicaid beneficiaries, but account for a disproportionate amount of program spending. Within that population, fewer than 5% of beneficiaries account for more than 50% of overall Medicaid costs.