In an ideal environment, care managers (most often specialty trained nurses), are experts in working with individuals to identify their goals and locate the specific support services that enhance the patient’s well-being. When faced with the array of choices and challenging decisions, care managers provide support to find the best solutions for individuals and their families.
Having been in the industry for nearly 30 years, I’ve both watched and helped lead change in this space. The healthcare community has moved from a very basic form of care management known as utilization management to today’s member portals and self-help tools. But health systems are finding they need something more significant. Hospitals and health systems have trained staff to facilitate a discharge, to navigate a patient quickly through choices for cancer or cardiac treatment or even outreach programs to attempt to avoid readmissions – yet most of these efforts are isolated within a single specialty or function and rarely look holistically at the patient and all their clinical and care issues.
For example: Cancer patients are rarely perfect specimens of health other than their cancer diagnosis. They likely have diabetes, or hypertension. Perhaps they have a challenging living environment at home, or they may live in a rural area outside the city with limited access to medical services. Or perhaps this is a recurrent issue and their overall health status is already compromised. Now consider the fact that nearly 50% do not have a primary care physician – the need for new care management models is obvious.
As we enter an era of bundled payment models and shared risk – having expertise in care management that merges the acute clinical situation with the underlying medical issues of the patient and their own symptoms, living environment, access points, knowledge and state of health is essential to improve outcomes and reduce costs.
The bottom line: The underlying business model of most of today’s care management processes is dated. It was built for a different era and for a different purpose. It’s time for a change.
Highlights of Legacy Care Management
Before the Affordable Care Act took the industry by storm in 2010, health plans were the primary group who cared about managing the health of populations. These payers cared a lot, because they had so much economically on the line. They needed data-driven systems that could help identify and manage patients who might incur large healthcare expenses at some future time. The care management industry was born out of this need.
What began as a simple notion in the early 1980s, has had layers upon layers added over the years with very little change in the underlying business model. These legacy care management systems look much like a ball of duct tape - utilization management, case management, disease management, wellness and prevention, financial incentives for providers and individuals to change behavior, predictive tools, provider portals, nurse navigators, member portals – all with good intention - but as relevant today as a VHS tape in a streaming media world.
These old style care management systems have certainly evolved over time, and they typically worked like this:
Within this giant ball of duct tape, each of the players – the health plan, the hospital system and the practitioner - have slowly figured out that they actually need the patients’ participation and deep engagement in order to make all this care management work. So patient engagement capabilities like online health records and employee wellness portals were added to the mix. But the patient was simply a by-product of a legacy system originally designed to keep providers “in line.”
The entire care management market is under serious strain – the underlying business model is mostly broken, costly to operate, employee heavy, and not scalable. The basis of analysis - healthcare data (claims) - is typically retrospective in nature, often delayed by one to three months. Without timely, relevant data, one cannot address today’s reality of needing to know, accounting for and supporting the day-to-day needs of individuals with significant medical conditions.
Care management data do not universally include the real time information required for critical insight. Even more important, there is virtually no patient reported data collected by anyone. At best, today’s data models are derived from claims, making a series of assumptions about the current patient status that are largely wrong. Without day-to-day patient reported information (especially for those who have significant illness), nothing changes.
The big gains from this entire care management approach have plateaued. Most of these programs are bloated with layers of beaucracy and largely out of touch with the individual consumer.
So what should take its place now? There are lots of buzz terms floating out there: Accountable Care, Population Health Management, Value-Based Care, Patient-Centered Medical Home. But in order to be different, it all comes down to this simple notion –the new business model of care management must involve a massive shift from silos of care management to strategic partnerships that include the patient, the provider(s), payers and technology-enabled strategic care partners.
To move away from the “we know best” model to a consumer-centric model requires transformational thinking of care management systems. For starters, we must focus on these 4 key areas:
Let’s face it; payers and providers have tended to butt heads since the first attempts were made to manage care by payers. But in the world of patient-centered care, these groups need each other more than ever.
With over 90 percent of the actual healthcare spend in the U.S. still based on the old fee-for-service model, the natural conflict between insurance companies and providers will linger for a while. The speed of technology innovation will always outpace the ability of any one payer or provider to truly deliver all the solutions a newly at-risk population healthcare model will require.
In all this, we must deliver on the promise of the Triple Aim framework developed by the Institute for Healthcare Improvement, which both optimizes the patient outcome while it optimizes the health system’s performance. These new care management models must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
One of the key objectives of care management, controlling the rise of medical costs, remains unsatisfied. And while the quality of care focus is having an impact, the United States continues to have one of the unhealthiest, costliest populations in the world. We focus more on the over-treatment than really understanding the patient’s goals and supporting them to have the highest quality of life possible. Furthermore, the experience of health care for many people is largely chaotic and unsatisfying.
It’s time to use our entrepreneurial and innovative thinking to bring a new care management business model to the market. Let’s work together to create a business model that is about people; individuals and their families with unique medical, emotional, spiritual, cultural, literacy, economic and social needs (the key determinants of health). It’s time for a business model in care management that actually is focused on the word “care” rather than “management”. That's what we're doing at Narus Health. After all, for those of us committed to this space, it’s all about Human Care.
Michael is an executive coach, entrepreneur, investor, and strategist with 30 years of experience leading investor-backed, high-growth organizations.
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