Value-based care is fundamentally altering the nature of health care in the United States. Care delivery is transitioning from an episodic, somewhat reactive model into a more proactive health management approach.
More and more often, provider organizations are accepting a per-member-per-month budget to manage the health of a population, and their incentives revolve around maximizing the health of this population. In addition, payers—including Medicare—are beginning to reimburse providers for chronic and complex condition case management under fee-for-service models.
As the reimbursement paradigm shifts from driving volume to maximizing value, physicians and hospitals are seeing that it makes sense to invest in services that don’t necessarily directly tie back to greater efficiencies or more patient throughput. And it’s making a difference in the quality of care and health of patients and populations, which should also translate to positive financial outcomes under risk-based business models.
When enabling risk, there are four areas where additional emphasis by providers can dramatically improve health outcomes through care management efforts:
- Investment in data and analytics
- Patient engagement
- Intervention improvement
- Reporting enhancement
Use data and analytics to identify at-risk populations. High-risk cohorts can be found by analyzing claims data from Medicare and commercial payers, when available, as well as clinical data found in electronic medical records and laboratory, radiology and pharmacy information systems. This data can also be benchmarked through large, de-identified clinical databases.
Applying advanced analytics, including predictive modeling, to clinical and claims data can help organizations find and stratify high‑risk patients, especially those with chronic conditions who are likely to be hospitalized in the near future.
Learn about your patients, then engage. With at-risk populations identified, most providers will want to jump straight to clinical interventions, but not every patient is going to respond positively to a blanket outreach.
Not only should you segment your populations by clinical risk or chronic illness, you should also apply that same level of targeted segmentation based on a patient’s propensity to engage. This can be done by analyzing and segmenting psycho-graphic, demographic and attitudinal data, along with collecting patient communication preferences. Develop a targeted communication strategy along with a clinical strategy.
Build on intervention successes. I recommend that providers initially focus on the core clinical interventions that support transitions of care and patients dealing with chronic and complex conditions. These services will have the greatest impact on reducing unnecessary utilization and readmissions, and can also support transitions and care path adherence related to bundled payment initiatives. The use of technology such as remote patient monitoring for patients with congestive heart failure can support improved engagement and clinical management.
Then providers can expand into specialty case management programs such as palliative care, cancer or ESRD based on the population’s needs.
Expand reporting capabilities. Reporting isn’t something you set and forget. Reporting helps organizations maintain a strategic, targeted approach with how they’re engaging with patients and the clinical effectiveness of their programs. Data from reports should be used to set up and enhance clinical interventions and programs to meet the needs of patient populations. As actions are taken based on report data, more detailed reporting is often required to monitor the effects of the new operations.
For more insight on enhancing your care management programs, check out the article “Care Management: Four areas you must evolve when taking on financial risk”, in the Fall 2015 edition of RISKMATTERS.