Healthcare costs are on an unsustainable path, 5% of the population contributes to over 50% of healthcare costs. Effective care management of the high-risk population is the key to sustainable healthcare. Health Plans are actively focusing on care management and wellness initiatives to contain costs and win in the consumer centric marketplace.
There is a revolution brewing in care management, here are top 10 things health plan executives should know about the looming change.
1. Focus on Outcomes Vs Activities
The industry is expecting higher focus on reducing ER visits, improving quality of life; driving significant cost reduction and providing a high touch engagement to achieve the behavior and decision-making changes required to achieve desired cost and quality outcomes. .
Ability of care management to meet members’ end to end medical, behavioral and social needs across fragmented services is becoming critical.
Risk sharing models with providers based on medical expenses, health status, Star ratings and HEDIS scores improvements are becoming the norm.
2. Traditional Care Management has Limits
Traditional care management has a number of widely acknowledged limitations. For example, the programs are likely to be:
- Dependent on outdated information to fuel analytics as opposed to real time point-of-care data that can dramatically enhance care coordination and overall quality.
- Siloed and nurse intensive, instead of taking a whole-person approach through a team of care coordinators connected to the local patient-physician relationship inclusive of behavioral health advocates integrated in to interdisciplinary care.
- Primarily telephonic and call center based, lacking the personalization required for true behavior change and less able to consider social, behavioral and cultural influencers (such as health literacy) and socioeconomic conditions (such as food security or access to transportation).
Changes are needed to set the framework for a care management model that looks significantly different than what health plans are used to delivering.
The author credits the material in this article to whitepapers from Optum. To download the detailed whitepaper please visit DistilNFO’s partner knowledge center here (https://www.distilnfo.com/kmc/)
3. Payment Basis is changing
The payment basis is changing from per member per month paid for activities to outcome based risk sharing based on medical expenses, health status, Star ratings and HEDIS scores improvements. Care management of the future will have to focus on outcomes and deal with the changing payment model.
Estimates show that care management can reduce costs by $705B (with guarantees and risk sharing as the entry price).
4. Member Expectations are Changing
Member expectations are changing–from expecting health service experiences to be fragmented, arduous, confusing, rigid and paid for by an employer or the government with little to no member choice. With increasing cost burden on the members, there is a significant demand for integrated, convenient, personalized and multi-modal experiences.
Engaging at an individual member level is the key differentiators in the market to win on exchanges.
5. Role of Care Management is Changing
The role of care management is changing from identifying individuals with care gaps and intervening on a case basis (leveraging internal staff), to identifying population health and care delivery system variations and outliers to enable systemic improvement (leveraging community resources, providers and internal staff through a community-based care model).
The author credits the material in this article to whitepapers from Optum. To download the detailed whitepaper please visit DistilNFO’s partner knowledge center here (https://www.distilnfo.com/kmc/)
6. Personalized Engagement is New Normal
Traditionally, care management has been telephonic. The modern model goes much further by deploying face-to-face, telemedicine, Internet, remote monitoring and other techniques to reach the patient in the best way possible.
Wearable health tracking devices are changing the landscape, there is increase in data monitoring and evidence of care impact measures. Large technology companies like Apple with Apple Watch and IBM with Watson are changing the care paradigm.
7. Need to Drive Coordinated Interventions
Many of the high risk members have multiple conditions, requiring a comprehensive coordinated care plan as a critical tool to better manage their care. Updates can be processed in real time as new and relevant patient information emerges.
A systematic way to timely coordinate care interventions is the difference between a patient ending up in ER or getting right care at the right time in a home setting. The cost savings from timely interventions significantly impact Health plans financials.
Health Plans need sophisticated platforms capable of helping care managers make decisions based on deep data analytics.
8. Focus is on Monitoring and Measurement
Success in improving the health of an individual member and larger population is monitored and measured on an ongoing basis. Different forms of engagement (for example, remote patient monitoring) are used extensively to track improvement over time and provide real-time feedback regarding the effectiveness of different care interventions.
Modern care management programs put data and analysis to use in unprecedented ways with and unprecedented level of precision, rigor and action-orientation.
9. Advance Analytics Creating Immense Impact
For modern care management to be effective health plans and providers have to be able to identify the right 10 to 20 percent of the covered population to address their distinct health needs. Although, models that identify and stratify populations are quickly becoming the industry norm, integrated clinical and claims data alone are no longer enough.
A fundamental change in approach driven by analytics to drive the following is going to be the secret to success.
- Whole-person data (pharmacy, medical, specialty, behavioral, social)
- Decision-making tools across the continuum of care that update in real time and can be accessed by all caregivers
- Dashboards that allow everyone involved to see the same member-specific information
Taken together, these elements inform an actionable care plan based on informed, integrated care coordination.
10. The New Care Management Model is Emerging
The modern model provides health plans with the edge that they need by removing traditional barriers to consumer engagement and creating opportunities for better health, in addition to improvements in STARs and HEDIS ratings, and financial performance outcomes.
Optum’s vision delivers the modern approach that enables care management to:
- Integrate whole-person health
- Support care provider engagement
- Emphasize the local market
- Deeply ground all actions in data, analytics and new technologies
This framework — particularly the ability to use actionable data and analytics to drive locally integrated care — defines the Optum care management model.
The author credits the material in this article to whitepapers from Optum. To download the detailed whitepaper please visit DistilNFO’s partner knowledge center at https://www.distilnfo.com/kmc/
** The views expressed in this article are of the author and do not reflect the views of DistilNFO or Optum.