Can the processes around complex care management be significantly improved? There are a lot of challenges, as David Lansky, Ph.D., and Jeff Micklos, J.D., write, in a January 31 article that appeared in NEJM Catalyst, an online section of The New England Journal of Medicine that publishes “content with a focus on improving patient care and driving value at health care organizations.”
In the article, entitled “Sustainable Financing for Complex Care Management Is Critical to a Value-Driven Health Care System,” Lansky, who is CEO of the San Francisco-based Pacific Business Group on Health, and Micklos, who is executive director of the Washington, D.C.-based Health Care Transformation Task Force, argue that a number of core elements of care management for patients with complex medical needs will have to be modified—some of them including federal policy and payment elements—in order for the U.S. healthcare delivery system to succeed in that important area. Indeed, the challenges are layered on several levels.
“Effective management of high-need, high-cost individuals is integral to the success and sustainability of a value-driven health care system,” Lansky and Micklos write. “These patients make up 5 percent of the population but account for more than 50 percent of U.S. health care spend. Complex care management programs coordinate essential services, address critical gaps in communication, and prevent costly, avoidable hospitalizations and other urgent care services. Evolving innovative programs even incorporate nonmedical services such as transportation, housing assistance, and proper nutrition, which address the broader socioeconomic influences of health. Ultimately,” they note, “complex care management is one of the best available tools to prevent costly and unnecessary use of the health care system—and improve patient outcomes in the process.”
Unfortunately, despite strong supporting evidence for their value, Lansky and Micklos write, “robust complex care management programs are not ubiquitous,” with sustainable financing a critical issue. The core problem? “Payers are supportive of care management services but may not adequately pay for those services outside of their own programs. This fundamental disconnect,” they contend, “creates a piecemeal system in which programs are not scalable across lines of business, and where not all high-need, high-cost individuals are appropriately identified and targeted for services. Without adequate and secure funding streams, providers may feel compelled to ration care—and innovative programs may be left to wither away after initial seed money runs dry.”
Essentially, they argue, “Care management should be payer-agnostic at its core. All individuals, regardless of how they are paid for, should have access to complex care management programs as their needs require.” And that’s why the Pacific Business Group on Health and the Health Care Transformation Task Force teamed up to write a report that received support from the Commonwealth Fund and the SCAN Foundation; and this article in NEJM Catalyst represents the public announcement of that team’s work.
Essentially, the authors report, “The study found that provider organizations were more likely to stint on care management if they didn’t have a strategic imperative from executive leadership to internally fund programs or equitable payer funding across multiple lines of business. Without either, providers offered limited services or reserved participation in complex care programs for individuals with higher-paying insurance.”
The authors go further, offering some specifics on the collaborative payer-provider contracts for complex care management that they see as essential for success in this challenging area. They see four clear categories of risk established by the Health Care Payment Learning and Action Network: fee-for-service with no link to quality and value, fee-for-service with links to quality and value, alternative payment models built on fee-for-service architecture, and population-based payment. And the elements involved in this complex puzzle include type and level of risk, data-sharing, the patient population involved, consumer engagement, service requirements, quality metrics/performance evaluation, provider network requirements, financial structures, return on investment, and confidentiality requirements.
They walk readers through considerations, including type and level of financial risk involved—which they believe should be determined following an internal return-on-investment (ROI) analysis by the provider organization, particularly when advanced risk models are involved, since breaking even financially on an advanced, risk-bearing contract, can be a crucial factor to consider.
Meanwhile, the authors note, any clauses around data-sharing can also determine how successful any complex care management contract will ultimately be, with such elements as where the data will be housed, how it will be transferred, and how it will be used, will help determine how successful the care management itself will be.
The authors share the same advice around defining the populations of patients/plan members for whom providers will be responsible. This becomes particularly important when it comes to engaging patients/plan members in their own care management.
In short, the devil is absolutely in the details here—which is probably one reason why not many contracts have been constructed specifically around complex populations, to date. Put simply, based on their research, the authors of this article are telling us that there is no way to stumble into success in this challenging arena. And there clearly is a geometric quality to the levels of challenges involved here.
Meanwhile, this also clearly seems like an area in which healthcare IT leaders can become heroes to their colleagues in patient care organizations, all the way from being involved with data and financial analysts at the outset of any initial negotiations, and through the contract-signing phase of any such initiative, through to the development and implementation of successful data analytics processes and information systems, which will be vital to the success of any such initiatives.
The reality is that this area—the management of patients with complex health (and often social) needs—is one with tremendous promise in U.S. healthcare; but it also involves almost mind-bending challenges, with layers of conceptual, operational, process, and data and information complexity. The leaders of the Pacific Business Group on Health and the Health Care Transformation Task Force should be applauded for their groundbreaking study of this important arena of activity. We can only hope that their work here, laudably funded and sponsored by the Commonwealth Fund, will yield real fruit, as the U.S. healthcare delivery and payment system lurches forward into the challenging, potential-filled future. If future-focused innovation in payment reform were a spear, this area would absolutely be its tip. And tips are sharp.
