Navigating the present healthcare system is like riding a boat in stormy seas with a floor made of sponge. It is designed to leak. As you plug one hole, another begins to flow. As you attempt to repair them one by one, you realize the whole basis is flawed. And the only way to fix it is to remediate the entire structure. Replace the floor.
A Comprehensive Care Management Model cannot be more of the same. While it may utilize the good and valuable aspects of the past, it needs to act on the basis of new incentives, new modes of payment and new alignments.
The new model has been discussed much in recent years and several business entities have adopted it successfully. I believe that this model is the right model in select communities where providers and physician groups are more savvy and integrated, where the opportunity is available and the market is mature.
How will this model be different from the past? A comprehensive approach to care management succeeds if it is
It is a switch from the sporadic to the continual, the fee-for-service to fee-for-value, to preventive care and primary care from tertiary care and population medicine from strictly individual approaches. It aligns financial and professional and administrative incentives and visions; it makes care seamless and it is a shift in culture and not just lip service in order to enhance profits. In short, it creates a truly integrated network where care is seamless, data is effective and control is in real-time.
It focuses on the long-term needs of all its customers and vendors; i.e., it is a win-win for all and is not a zero-sum game. And the key to it all is the best customer service under any and all circumstances. How can this be achieved?
The goal is to create a standard and repeatable customer experience. This can be managed by improvement in technology, a drilling down of the new culture through rank and file, and synergy of goals, systems, processes and people.
To my mind, these are the steps:
- An IT system that creates one platform for claims, data, reporting, analysis, quality metrics, compliance measurement and utilization. For this it must create a seamless experience through one EMR, EHR, claims system, customer service, physician portals, provider credentialing and education, financial information and report cards, paid claims and pending claims, lab reports, emergency room testing, and studies done in various facilities including the hospitals and a third-party administration of the entire gamut of healthcare. IT is one of the most critical elements of CM.
- Operational processes that create continuity of care in outpatient and inpatient settings and are able to fine-tune responsively to changes in regulations, requirements and needs of patients. Such processes need data that is integrated, immediate and actionable, and able to intervene with laser- sharp precision.
- Team-building and structural refinements: Without the right people and the right team, all the systems will fail. The team needs to spend time with each other and learn from each other, following that 10,000 hour rule as described by Malcolm Gladwell in the book Outliers, creating a learning organization and a knowledge organization.
- Physician training: Without the right physicians, this model will not succeed. The right training and education of physicians starts with medical school, or even earlier, continues through residency and fructifies during their practice of medicine.
- Reporting that is constant, measuring of outcomes and interventions and ensuing results is critical. One must be able to quantify the results of evidence-based protocols and the numerators and denominators of various indices. We should be able at a touch of a button to see all patients with, say, a HgbA1c greater than 9, LDL-c greater than 100, all high-cost patients and MRA, HEDIS, etc. We cannot forget clinicals that are not coded and billed, such as CPT-2 claims, labs in hospitals, etc.
What are the requirements of a successful CM team? These would be:
- An experienced medical director
- Strong leadership from the highest level of the organization
- Qualified supervisors, team-leads and case managers
- IT systems, including software, phone and recording systems
- Care Coordination Centers to bring it all together
- Constant training, learning and interaction
These are the requirements in an inpatient setting:
- A trained Emergency Room Department
- Aligned hospitalists
- Embedded case managers who track the care of every patient
- Shared EMR and software
- Educated and enlightened special services such as intensivists or trauma services, etc.
On an outpatient setting, these are the requirements:
- Staff-model clinics which create a one-stop shopping experience for patients, providing ancillary services and specialty testing
- Special clinics and programs, such as fall prevention programs, diabetes clinics, coumadin clinics, CHF clinics, etc.
- Urgent-care clinics which provide round-the-clock service and are able to prevent unnecessary ER visits and readmissions
- Centralized referrals
- Processes of approval and denial mechanisms
- Provider education and training on a constant basis
- Staff education and training on a constant basis
- Embedding patient advocates and liaisons in each practice
- Community centers, adult day-cares, access centers, and creation of community resources to help the indigent
- Population education through lectures, literatureand engagement
- Appreciation of the holistic nature of medicine and healing
Of course, there is more. The integration occurs at the cracks where the patients fall through. These cracks open up at the time of discharge from hospital or SNFs, ER visits, specialty visits, ancillary services and testing and out of town visits. This is where CM needs to be most intense and is able to work with patients due to the relationships built with them in the inpatient and outpatient settings. In essence, each patient needs to have periodic follow-up and contact. At this point, one of the most important concepts in CM comes up and that is risk stratification. These are the patients not seen, those who are outside the system or are non- compliant or have behavioral or psychiatric issues or social or family problems which impede good healthcare. Also included are those with serious illnesses who undergo multiple admissions to the ICUs or have multiple interventions, or patients needing end-of-life or catastrophic care.
A good CM model focuses on PQRS and meaningful use, on Star ratings and HEDIS, on HOS and CAHPS. By thus aligning with the interests of payer and providers, it assists the health organization to get better contracts with payers, develops long-term and mutually profitable relationships with vendors and providers. The new models of payments like Shared Savings, Bundled Payment Programs, Global Risk Agreements and Fee-For-Value make such a model immediately profitable.
It is my opinion that a good care CM model will improve customer and provider satisfaction and is a situation where the journey is the reward, regardless of financial returns which, nonetheless, will follow. Here we stop following the money trail but follow the quality trail and the money trail, too, will follow.
The Comprehensive Care Management Model is like the complete integration model for Apple and advocated by Steve Jobs as against the open model followed by Microsoft. In my opinion, the closed model of care enhances patient care, services and all that accrues (or should accrue) from doing a great job in medicine: professional satisfaction and healing that create a great healthcare organization.