Where Should Care Management Reside in the Healthcare Continuum?

In today’s COVID-19 environment, care management has become more important than ever. Currently, about one in four Americans live with multiple chronic conditions, and when one considers that 80% of outcomes are determined by nonclinical factors, it’s an indisputable claim that people need help between healthcare encounters. If we are determined to move towards value-based care, patient communication and care management needs to extend beyond the four walls of a doctor’s office. The ideal scenario involves a comprehensive, holistic solution that addresses lifestyle and socioeconomic factors, in addition to physical conditions. The question then becomes, where does care management fall in the healthcare continuum? When it comes to providers and health plans, which group is better suited to “own” care management?

Care Management’s Current State

For a variety of reasons, care management predominantly resides with health plans – the most important of which is their ability and need to adopt certain technologies that can effectively identify, engage, and understand the needs of comorbid individuals. Importantly, health plans have the financial wherewithal to be able to integrate these digital solutions; providers, generally do not have the resources and funding to do the same.  However, health plans also face unique expectations that position them to be forward-looking organizations, such as their performance with regards to member engagement and satisfaction, graded by CMS in addition to state and federal entities. In fact, according to the Kaiser Family Foundation, 72% of Medicare Advantage members enrolled in plans with four or more stars in 2019, and plans that fell below that star threshold would face decreased enrollment, and consequently, financial loss. In today’s world, integrating digital health management isn’t a competitive differentiator for insurers, but rather, an unassailable requirement.

Another important distinction to make between payers and providers, as it relates to technology adoption, are their windows into the patient journey and the underlying data available to them. Where health plans have insight into crucial information such as a patient’s network of providers, treatments, claims, payments, and benefits – information that creates the full picture of the patient – providers are not privy to the same knowledge. And for care management to maximize its full potential, the system needs to take into account all of these factors in addition to the patient’s socioeconomic status. By meeting both clinical and social healthcare needs, care management can comprehensively treat chronic patients by collectively addressing all of their chronic conditions in addition to delivering personalized health education that can improve their lifestyles. Health plans’ ability to harness the data available to them through digital solutions inherently gives them an advantage with administering care management.

The Impact of Healthcare Transformation on Care Management

As healthcare adopts a more value-based model, the question of who should own care management calls into question whether or not it should be siloed to a particular field. We need to consider how it can be most beneficial to the industry, and more importantly, the chronic population. There is an increasing trend that payers and providers are taking on new payment models that share accountability to manage total costs while improving quality outcomes. This is evidenced by contracts driven by accountable care organizations (ACOs), where providers are taking on more downside risk by making their financial success contingent on their management of chronic illness. While not a universal standard yet, this unification between payers and providers opens the door for providers to leverage health plans’ care management systems and the integrated digital solutions. Not only does this allow practitioners to focus on the relationship between cost and quality of chronic management, but it also provides a multitude of other benefits that providers can reap. Specifically, advantages include highly scalable patient outreach and communication; patient activity insights (e.g. physical activity or medication adherence); insights on social determinants of health, and patient reported outcomes via advanced algorithms. Importantly, it also enables providers to leverage a wide swath of clinical programs including behavioral health and maternity services which they may not have at their disposal.

The Best Path Forward

With the growing proclivity to a new model of healthcare, care management simply cannot live in a vacuum. Payers and providers must partner to leverage data to manage cost, quality, and outcomes, and care management is an excellent vehicle to achieve this for the chronic disease population. While this collaboration trend is taking place across the healthcare continuum, a lot of work has to be done before the industry reaches an optimal path forward. Ownership of care management may reside with payers for now, but ultimately it will, and should, be a holistic function between payers and providers.

Susan Beaton R.N., is vice president of Health Plan Strategy at Wellframe.