Traditional care management is facing increased scrutiny under mounting expectations. Expectations of better utilization management and cost control. Expectations that the increasing number of members entering the market through exchanges will receive better quality care.
But for care management services to achieve genuine success, there must be substantiated value in regard to improved health outcomes, in addition to stable and reduced costs. It is vital that care management services:
- Comprehensively address the needs of complex, high-risk and high-spend members.
- Provide personal interaction and engagement that helps change behavior, and allows members to make more informed decisions about their health care.
- Meet the member’s end-to-end medical, behavioral and social needs across fragmented services.
Health plans have the right to expect more of their care management support as they spend considerable dollars on these services. Health plans also stand to benefit the most from a healthier population, especially among Medicare and Medicaid members.
Change is coming
Significant aspects of care management are changing in fundamental ways. These changes will establish a new framework for care management models going forward:
- Payment basis is transitioning from per member/per month to outcome-based risk sharing.
- Members have gone from expecting little of their health care, to demanding — and now paying for — many choices.
- Care management providers are looking at services beyond a case-by-case assessment to identify opportunities to improve care at a population level through locally delivered, integrated services.
Placing members at the center of care management
Members will be at the center of care management models in the future, creating a whole-person approach to supporting care. Care providers from all angles — primary, specialty and behavioral — will need to move in lockstep with each other. They will have visibility to and influence over a member’s care plan, including actions around pharmacy and social determinants of health.
As such, care management success or failure will hinge on three important activities:
- Define local engagement
- Drive coordinated efforts.
- Enable monitoring and measurement.
For a deeper look into meeting the challenges of care management, including relevant case studies, download “Modern care management.”
–Robert D. MacArthur, Jr. MD, MS
Dr. Robert MacArthur currently serves as the National Medical Director for OptumCare’s Complex Population Management. Dr. MacArthur previously served as Regional Chief Medical Officer for United Health Group’s Medicare programs for vulnerable seniors, and as a market Medical Director for Optum of North Carolina. Prior to his position with United Health Group, Dr. MacArthur practiced Internal Medicine and Geriatrics in Greensboro, North Carolina.