Acting Like A Payer & Provider…It’s Good For Everyone’s Health

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There’s been a lot of talk about the care management and coordination approach organizations should take. Traditional health and human services agencies are being asked to manage/coordinate care for clients or patients. It’s important your organization’s partners share your vision. The collective we are responsible for the care of an individual — even when the services are not directly provided by the organization. When coordinating care, the case managers become the care managers.

On the other side of the coin, there are traditional health plans, or Managed Care Organizations (MCOs). These organizations manage a population of individuals and view their population as members or participants. They track provider performance against certain quality measures such as reducing emergency department utilization, or ensuring a member gets a metabolic screening annually if they’ve been prescribed an anti-psychotic. In addition, they control costs by pre-authorizing services. For the most part, this is done by analyzing claims data. Claims data is a good source, but will always be retrospective. The members will be stratified based on how much they cost. The riskiest folks cost the plan the most.

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As organizations are asked to manage populations and begin to walk down the road to become health homes, they’ll need to separate care management from care provision. This separation is critical; the care managers in this model will be the quarterbacks for a team of folks and their perspective needs to extend beyond the walls of your organization.  The ability to separate will depend on the size of the population. The larger the population, the easier it will be to separate your care managers from case managers.

Enough theory, let’s dive into an example. Assume a percentage of your population will be high risk, medium risk and low risk.  A good strategy would be to move between managing high-risk individuals in the community, where the caseload may be around 50:1, to medium risk at 150:1, to the low risk folks at 400:1. These numbers might be different and would increase as organizations take on larger populations.

As you’d imagine, a caseload of 400 members is very different than a caseload of 50 members; the tools required for this type of work might as well be on opposite sides of the spectrum. Managing the low risk group is best described as list/registry management, while the high risk will take more of a care coordination or case management approach. As a partner in your success to creating healthier lives, your software and technology partners should play an active role in whatever approach best fits your organization. We believe in partnering and sharing your mission as you make this journey.

Which course is the best to take? Claims management and registries…or focus on applying case management techniques to the population? My opinion is that a hybrid approach is the most effective course for us to take together. To handle the high-risk folks, we need to drill down to the individual level and address the specific needs of the person. It’s not one or the other; we’ll need a perspective on the population as well as the individual person.

Whether we call them members, patients, clients or consumers, the only way we’re going to move the meter, improve lives, and bend the cost curve is to drive knowledge gained at the population level down to the point of care. Now is the time for us to be proactive.