Looking at Fragmented Care Management, One MD Leader Envisions the Future
On June 16, 2023, JAMA Health Forum published an article by a team of healthcare policy researchers, entitled “Reframing Value-Based Care Management: Beyond Cost Reduction and Toward Patient Centeredness.” The article analyzes the current strategies to advance value-based care through care management of patients with living with chronic illnesses, and finds significant challenges in leveraging the care management requirements in alternative payment models (APMs) and accountable care organization (ACO) designs.
The article’s lead author is Priscilla Wang, M.D., M.P.H., a senior leader at the 12-hospital, 1,300-primary care physician integrated Mass General Brigham health system in Boston and a practicing primary care physician. Her coauthors are Maryann Vienneau, Christine Vogeli, M.D., Ph.D., Katherine Schiavoni, M.D., Lindsay Jubelt, M.D., and Mallika L. Mendu, M.D.
The healthcare policy researchers write that “Care management programs are increasingly being utilized by health systems as a new foundational strategy to advance value-based care. These programs offer the promise of improving patient outcomes while decreasing health care utilization and costs. However, as these programs proliferate in number and specialization, the field of care management is increasingly at risk of fragmentation, inefficiency, and failure to meet the core needs of the patient.”
Further, they wrote, “This review of the current state of care management identifies several key challenges for the field, including an unclear value proposition, a focus on system- vs patientcentered outcomes, increased specialization by private and public entrants that produces care fragmentation, and lack of coordination among health and social service entities. A framework is proposed for reorienting care management to truly address the needs of patients through acknowledging the dynamic nature of patient care needs, providing a continuum of need-targeted programming, coordinating care among all involved entities and staff, and performing regular evaluations of outcomes that include patient-centered and health equity measures. Guidance on how this framework can be implemented within a health system and an outline of recommendations is provided for how policymakers may incentivize the development of high value and more equitable care management programs.”
Wang and her fellow authors conclude that, “With increased focus on care management as a cornerstone of value-based care, value-based health leaders and policymakers can improve the effectiveness and value of care management programs, reduce patient financial burden for care management services, and promote stakeholder coordination.”
Dr. Wang, whose current title is associate medical director of primary care health equity, spoke recently with Healthcare Innovation about the context of that article, and shared her perspectives on the path ahead in terms of advancing care management in alternative payment models, as seen through a health equity lens. Below are excerpts from that interview.
Tell me a bit about the context of the article, and why you and your colleagues decided to write it?
When I wrote the article, I was the clinical lead of several of our Medicaid ACO care management programs. Now, I am engaged in focusing on encouraging the advancement of care management, through the lens of equity, with a focus on community health workers. Per that, there is the broader mission of population health management at Mass General Brigham. The role of the care management team is to support patients with social and medical complexity. So there’s the underlying motivation of aligning that with our mission. The focus of the team: emphasis on a person-centered or patient-centered approach to achieving their health goals.
We’re such a sick care-focused system. And Medicaid is a vulnerable population. What’s the answer?
Especially for me as a primary care doctor, we want to promote the positive as well as prevent the negative. And though many leaders have expressed the desire to shift to wellness, my worry is that our metrics are still short-time-bound and focused on acute-care episodes and the negative, instead of broadening the aperture. If we really are committed to that positive mission, the timescale for success can’t be measured just by preventing ED visits or hospital admissions.
Those programs don’t see the person as a whole person, but instead, inevitably, as an assemblage of body parts and systems, correct?
Exactly. Patients are being carved up in different ways, and these programs are looking at different parts of a person, as opposed to looking at the continuum of patients’ lives. And just purely from an efficiency/cost standpoint, you’re just building more inefficiency into the system if you’re building more programs that are duplicative and fragmented. Also, from the patient perspective, if you’re being contacted by all these programs, it’s frustrating and confusing, and hinders us all from really working together; it’s just worsening this fragmentation issue.
In that context, how do we enhance the health of Medicaid patients?
I am so excited by the potential to create real change inside the Medicaid program. To be sure, there’s so much activity going on in the Medicare Advantage program; but many of those startups are focused on gaming the reimbursement system, even while they’re doing so for good purposes. In Medicaid, there’s the double whammy for patients of living with medical complexity and comorbid conditions, and at the same time, the patients are seeing the carve-up of their social dimensions, too. Someone might be reached out to around their diabetes or hypertension, and also, there are so many social programs reaching out as well. For example, I had one patient who’s homeless, living in a homeless shelter; he has a nurse caring for him in the shelter, a Department of Mental Health mental health caseworker; a community health worker through my clinic; and a housing advocate through some other venue as well.
That sounds very confusing; and it shows that that patient is being cared for in a very fragmented, non-coordinated way, correct?
Yes, that’s right. So what’s the solution? We need better understandings and partnerships among these programs. I had worked on our Community Partners program—a Massachusetts Section 1115 waiver—they made it mandatory for every ACO to participate in this Community Partners program. It was very well-intentioned. We had to work with 26 behavioral healthcare programs. But it was clear to me that this would never succeed unless our health system partners could understand what the care coordination programs could offer, and they struggled finding the right insertion points into the health system. So there needs to be a better understanding of what each can offer. So there needs to be a team-based coordination approach with what I call a coordinator of coordinators—a single person who can appropriately delegate to these programs. I think there’s value to these specialized programs, but I don’t think that health systems should be trying to solve housing issues or mental illness in the community; there has to be a team-based approach.
How should health system leaders be thinking about this entire landscape, and how they can strategize forward?
I was just on a panel in the food insecurity space on this subject. One thing that’s helpful is that we’re at an inflection point for moving past the acknowledgement simply that the social determinants of health exist, but where we’re going to start seeing efforts to operationalize SDOH, not as an “extra” but as a key part of the clinical workflow. One of my concerns—where healthcare leaders can be thinking proactively—is how we move past performatively checking off boxes that the Joint Commission and [Centers for Medicare and Medicaid Services] are asking us to execute on—to collect, store, and act upon data in an impactful way for patients. There needs to be a way, with a patient-centered approach, to make sure it’s all flowing to the same place, so that you really get a full picture of a patient. And the second piece is that I think we have an ethical obligation to act on this information.
And what we’ve learned at Mass General Brigham over the course of more than a decade is that it’s not a one-size-fits-all kind of solution; think along a continuum and about tiered complexity. We’re trying to build out a tiered approach. Some individuals just need a quick call and connection to an agency; others have a lot of social issues going on and might need handholding support over months with a community navigator or health worker; others have cancer, chronic diseases, and need more intensive care management. And then finally, people might have severe substance abuse disorder that’s impacting their ability to interact with the healthcare system; they might need an intensive wraparound model. If health system leaders think about this in a continuum, it makes it much more manageable. It helps us segment groups and think about the programming. I’m working on the clinical disparities side, through the use of community health workers.
Is there anything you’d like to add?
I think we’re in a very exciting place. We’re at an inflection point. There’s a real opportunity for positive movement. But there is a danger, that well-intentioned efforts can sometimes hinder actual, substantive work, if it’s not done thoughtfully and in a standardized way. And on the care management side, care management programs are coming out of the woodwork everywhere. And I have a real worry that there is not thoughtful consideration about what quality care management looks like, and how to implement it in a way that is person-centric. So part of the key that we hope people will take away is that health systems and payers will be able to commit not only in principle but in dollars and structures, to focus on a broader definition of value, in the context of a person-centric approach; and it requires the financing as well.
