Tight payer, provider connection gives local plans advantages

January 1, 2012

Advocates for community-based plans are driving the message that they can and do provide value.

NATIONAL REPORTS-Since adopting a medical home model in 2006, Geisinger Health System has reduced hospital admissions and 30-day readmissions for participating patients by 20% each. Advocates for community-based plans are driving the message that they can and do provide value.

Geisinger's program has expanded to include sites that serve half of the plan's Medicare enrollees and nearly one-quarter of the 180,000 commercial lives that Geisinger covers, says Janet Tomcavage, vice president of health services at the provider-led health plan.

"We emphasize to our providers that this is your medical home," Tomcavage says. "You need to do what works for your practice, your patients and your community."

As another example from the report, between January and July 2011, Group Health Cooperative reported total cost savings of more than $2.5 million for patients in its case management program. In both examples, nurse case managers were embedded within the practices to become an integral part of healthcare delivery at the site of care.

"Fifteen years ago, we had nurses who were integrated in practices, but they were not seen as an integral part of the practice," says Tomcavage. "They were seen as health plan nurses."

The idea of care coordination is emerging as the foundation for patient-centered care, especially for those with chronic conditions. CMS has been piloting medical home projects since 2007, and the ACHP report appears to back up the advantage of care coordination to improve patients' quality of life while saving money.

DUTIES OF THE CASE MANAGER

ACHP focused on five common themes among the work of community health plans: physician partnerships; face-to-face encounters; multi-disciplinary teams; appropriate use of technology; and community mindedness.

"The report opens an important window on what care management should look like," says Patricia Smith, president and CEO of ACHP.

Group Health Cooperative's plan embeds nurse case managers with physicians who are centrally managed to keep the nurses from getting pulled into clinical management, says Emily Homer, executive director of care management at the Seattle-based plan. Each case manager assists up to 50 patients with care coordination, managing the 30 days following a hospital discharge and providing overall case management.

The nurse uses his/her judgment in tandem with physicians to select which patients to follow. A patient with three or more chronic conditions is a prime candidate, as is a patient with two complex conditions.