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Payers seek to balance care management goals


A dearth of informatics to confirm the intuitive benefits of wellness makes it difficult for a numbers-driven health insurance system to know how to invest its resources

As healthcare management shifts from episodic, fee-for-service care toward a broader focus on population health and wellness, plan executives find themselves with one foot in each doorway. They recognize the true goal of health management, yet they currently lack the data to confirm success of programs in reducing claims.

That leaves them to wonder how they might allocate resources to “softer” wellness goals under new models of care when it is difficult to forecast future health needs of a population. Creating effective applications of wellness within ACOs is just one example.

A dearth of informatics to confirm the intuitive benefits of wellness makes it difficult for a numbers-driven health insurance system to know how to invest its resources, says Martin P. Hauser, CEO of Akron, Ohio-based SummaCare Inc.

The transition from disease care to disease prevention has been underway for more than three decades, he says. However, he sees traction now in the way the Affordable Care Act (ACA) is helping to reduce unnecessary utilization, help patients manage their health conditions, and focus on health and wellness.

“Those are all things we were talking about in the ‘70s and ‘80s,” he says. “It’s kind of ‘shame on us’ as an industry-the whole healthcare industry-because we’ve been talking about these things all along but we haven’t been able to make the changes.”

Now, the ACA is driving reforms through the Center for Medicare and Medicaid Innovation’s demonstration projects in new payment and service delivery models.

“There’s finally a sense of urgency and a burgeoning platform that will make this happen,” Hauser says.


Sick Care

But the industry still remains largely focused on sick care. Experts frequently cite the Centers for Disease Control and Prevention’s finding from 1992 that indicted the United States only spends 3% of its healthcare dollar on prevention, or a more recent Altarum Institute study that reports the nation spends about 9% on prevention.

“Until we really change the way we pay for healthcare and move from a sick-care system to a healthcare system, where we create incentives for providers and consumers of care to focus on their health instead of their sickness, we’re going to struggle with this. Most of the financial models are still focused on paying for sickness,” Hauser says.

Paula Sauer, vice president, Care Management, at Medical Mutual of Ohio, agrees that the industry is largely a sickness-focused system. Most plans can manage disease but preventing the disease in the first place is far more challenging.

“It’s a soft-type of savings,” Sauer says. “It’s a lot easier to measure disease management.”

Even so, experts continue to question whether preventive care investment really saves money in the long run. What’s difficult is predicting future costs and preventing them patient-by-patient.

Guided by ACA and research aimed at population health management, health systems have committed to transform care delivery and are working to develop bundled-payment models and vehicles that incent providers to schedule preventive visits. The transition is not easy.

“The challenge for all hospitals and health systems and individuals as a whole is how to get across that bridge. Most things are paid now under a fee-for-service model, and you don’t do things for people who aren’t sick,” Hauser says.

Hospitals and doctors are just now being rewarded using metrics for keeping people healthy, but rewards are largely bonus payment with little downside risk. While the models are changing, accountable care is still the exception rather than the rule.

“We’ve got to figure out ways to help insurance providers create meaningful, shared-savings models that encourage these changes of behavior,” he says.



Care coordinators            

Proving the return on investment in disease management can be straightforward, Hauser says. SummaCare’s outreach nurses call members to make sure they fill prescriptions get to physician  appointments after they’ve been diagnosed with chronic disease. Return is measured by reduced hospital and ER visits and related spending.

Some health plans are moving away from traditional fee-for-service, disease-management models with the use of care coordinators and case managers who work with patients as a complement to their physician visits. This type of care coordination forms a key attribute of the industry-led population health model advocated by the Population Health Alliance (PHA), formerly the Care Continuum Alliance. The model also calls for primary-care physician visits and patient activation.

Provider-based organizations moving toward population health management are beginning to place care managers within their practices to oversee groups of patients, said Frederic S. Goldstein, interim executive director of PHA.

Such care might range from phone calls or personal visits from a health coach to call center managers who receive biometric measurements from patients in their home via mobile apps or remote monitoring tools.

Care coordinators monitor diabetes, high blood pressure, heart disease, chronic obstructive pulmonary disease, emphysema and other chronic conditions. They also oversee lab tests and results, and encourage participation in wellness programs by contacting patients through a variety of means, including text message, phone, and face-to-face visits.

“The doctor sees patients four to 10 hours a year,” Goldstein says. “The question is, what are patients doing during the thousands of hours that they’re not there? Are they exercising, for example? Do they have access to healthy foods? It can’t just be a straight medical approach.”

Care coordinators help ensure a smooth handover of a patient during transitions in care, and they help activate patients to take charge of their own health, says Nancy Skinner, president of Case Management Society of America.

She sees patient activation as essential to improving healthcare.

“I’m very passionate about the fact that healthcare has always been paternalistic,” she says. “We need to make it patient-centered.”

While many stakeholders talk about the idea of “patient-centeredness,” high-touch care coordinators are the real-world application of the theory.



Shared responsibility

The use of care coordinators is a first step in sharing the responsibility and risk of patient health, Skinner says. Care coordinators help to open the pathways between providers and payers to increase understanding of the services available through payers, she explains.

Interoperability in IT systems is the only way to connect patients, physicians, payers and pharmaceutical companies. And the information must be available in real time for proactive outreach. Otherwise, retrospective claims data would be the only clue to connect the dots for patients-often months later.

For example, when a patient is diagnosed in a physician’s office, the physician could see that her Medicare Advantage program or insurer offers a chronic disease program at the point of diagnosis. The patient could be connected with the pharmaceutical company’s educational materials, and a care coordinator could track her progress between physician visits. The same is true when a patient is at-risk for developing a chronic condition.

“We all don’t have to do it ourselves,” Skinner says. “The walls that are built up between providers and payers are slowly coming down. We’re not going to sing ‘Kumbaya’ tomorrow, but we’re starting to develop stronger relationships to benefit the patient.”

Despite what she sees as the benefits of case management, less than 4% of Medical Mutual’s patient population is tended by a case manager because such care is labor-intensive, Sauer says.

Employers once considered wellness programs superfluous because they couldn’t see the return on their investment quickly enough, SummaCare’s Hauser says. Meanwhile, physicians were suspicious of health plans’ care management and wellness programs because they feared interference in the patient-doctor relationship. Employers and physicians are recognizing the value in collaborating with plans to promote member health.

“I think we’re starting to see a very positive transition where we’re recognizing the case team is an extension of physicians’ offices, and it’s a valuable resource in managing a whole continuum of care rather than episodic illness,” Hauser says. “We’re still early in the journey.”


Jennifer Webb is a Medina,Ohio-based freelance writer.


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