Category Archives: Medicare

Making Care Management Work for ACOs

An article in the May 2017 issue of Health Affairs, Bending The Spending Curve By Altering Care Delivery Patterns: The Role Of Care Management Within A Pioneer ACO by John Hsu and others from the Massachusetts General Hospital and Partners HealthCare in Boston, provides more evidence that care management interventions can meaningfully contribute to the performance of an ACO.  Doing so, however, is neither fast nor easy.

Here are a few key takeaways (which parallel my own experience):

1.  Target higher-risk populations with modifiable risk factors which your program is specifically designed to address
2.  Stay constant to purpose … utilization (ER visits and hospitalizations) may even go up at first … but will, as participants are in the the care management program longer, progressively decline over time (most notably at 13+ months)
3.  Sophisticated analytics and study designs are required to assess the impacts of such programs in ‘real-world’ implementations (i.e., without a randomized controlled trial)
4.  Inability to serve the entire target population should not deter continued implementation – enroll as many as current resources permit and continue to work toward expanding capacity

The care management program described in the article shares some attributes with HQP’s Advanced Preventive Care model.  One of the authors of the Health Affairs article was also an author on a 2014 issue brief for the Commonwealth Fund that identified HQP’s model as one of four (out of 18 successful models reviewed) having the highest quality evidence of effectiveness in managing populations with complex chronic disease. The details of a care management program’s design and implementation are critical to its success, with many varieties of “generic” care management have been found to be ineffective.

While not quick or easy, the path to improving population health – from both a health outcomes and cost perspective – is becoming clearer. The advantage will go to those with the know-how, relentless commitment to innovation, and constancy to purpose.

A rare delivery system reform – using a little know-how

Better Care Lower Cost Act - a rare delivery system reform
Better Care Lower Cost Act press conference Jan 2014

Insurance and payment reforms are often (wrongly) equated with delivery system reform.  Or they are assumed to be all that is required to ‘incentivize’ stakeholders to ‘transform’ their systems of care through ‘innovation’.  Lamenting the repeated failures of such efforts, yesterday a colleague remarked to me, “… maybe a little know-how would help”.  Now a new bill introduced into the Senate by Ron Wyden, D-Ore. combines the necessary alignment of financial incentives with a “little know-how” to make it more likely that we can have better health and lower cost for chronically ill Medicare beneficiaries.  The know-how comes in the form of incorporating key elements of care delivery that we have learned through many years of hard work and rigorous research are essential to improving chronic care.

What Kinds of Know-How?

Things like; a comprehensive assessment to individualize care, a care plan, collaboration among a team of providers, a commitment to develop and use measures of patient-centeredness, and many others.  The bill also recognizes the value of continuing to advance our knowledge of this still emerging field by establishing Chronic Care Innovation Centers, “to develop and implement a sustained research agenda in the field of chronic care.”  There is no question that the challenges are great, constancy of purpose is required, and no one bill or demo project will solve everything.  But a good proof of concept already exists.  The work and results my team at Health Quality Partners (HQP) have achieved in traditional fee-for-service Medicare and Medicare Advantage populations is one such example.  This should drive us boldly forward with discipline and a burning hunger to further improve these models.  Models that will work everywhere, even in areas of the country lacking mega-integrated-health-systems.  

Disseminating these kinds of new care models on a larger scale will take more than simply trusting to the current chaotic, often conflicting ‘health care market forces’ now in play in the U.S.  Leaders from physician groups, health systems, public health, and health insurance plans, willing to commit to these kinds of new care models need a better framework that provides the right incentives, flexibility, and a little know-how.  That’s what the “Better Care, Lower Cost Act” offers.

See for Yourself

Here are links to the press conference announcing the bill and a copy of the bill itself.  There is a lot in the bill, but the language is clear and it’s worth a read and reflection.
YouTube clip of the press conference: YOUTUBE_PRESS_CONFERENCE_CLIP
A pdf of the bill: FINAL_BETTER_CARE_LOWER_COST_ACT_011414

The Bill’s Sponsors

Senators Ron Wyden, D-Ore., and Johnny Isakson, R-Ga., and Representatives Erik Paulsen, R-Minn., and Peter Welch, D-Vt.  I got to briefly meet these members of Congress before the press conference and I was impressed with their thoughtfulness, desire to solve real problems, and their commitment to putting vulnerable chronically ill, older Americans above politics.  Bravo and thanks!