Health IT

Team-based care: The new role of the payer

I recently sat in a conference room with an executive of a major health plan located on the East Coast. He made a statement that illustrates the perspective of payers across the country: “We [as payers] are uniquely positioned to see all the care activities around an individual member. Yet, we struggle in our ability […]

I recently sat in a conference room with an executive of a major health plan located on the East Coast. He made a statement that illustrates the perspective of payers across the country: “We [as payers] are uniquely positioned to see all the care activities around an individual member. Yet, we struggle in our ability to engage and build a meaningful relationship with members to help facilitate the best, most cost effective care.”

Implicit in his comment is the desire of many payers to change how they interact with their members and engage them in a long-term relationship. During this ongoing and ever-changing healthcare evolution, payers have an opportunity to play a new and valuable role within the team-based care model to facilitate the delivery of high quality, economically efficient care to patients.

In my experience, payers want to be a member of the care team, but are unfortunately siloed and often out of sync with patients and providers. Payers have a vested interest in establishing loyal and collaborative member/provider relationships – to bring together all constituents that were previously acting in silos.

As the patient travels across care settings, payers have consolidated data to understand the team, processes, and events associated with the care of the patient. Many activities of patient care are invisible to individual providers because they see only the activities that occur within their clinic or that are accessible within the electronic health record (EHR).

With today’s healthcare information technology, payers can access team composition, team engagement, patient engagement, and understand the many dimensions of teamness associated with the activities of patient care. I want to outline three specific opportunities that payers can drive to support team-based care: (1) data driven case management in an integrated care model, (2) patient and caregiver engagement, and (3) provider collaboration.

 Integrated Team Model: Data Driven Case Management

Payers should leverage their unique access to data to support case management for members requiring complex care moving through a range of providers, care settings, and even care at home. In my work with different payers, I see them deploying different case management models which can be categorized into three blocs.

The first is a disease-focused model, the second is a model in which coordinators are embedded into their practices, and the third is a centralized model in which case managers focus on high-risk members. At the same time, other healthcare organizations are also deploying case managers to engage with patients.

A few weeks ago, I sat with a Medical Director of a New England healthcare organization and listened to him describe the implications of disjointed case management. He described the experience of an elderly patient transitioning out of the hospital to a skilled nursing facility (SNF).

Over the course of three days, the family was approached by the four different case managers from the hospital, ACO, SNF, and payer. Each had a different plan and different platform to manage the patient’s care.  Additionally, this patient had a range of other team members – specialists, nurses, physical therapists, and administrative staff all touching the patient with no means to universally manage and communicate across the team.

Technology is now available to manage and consolidate these channels of communication and activity, and payers should see the incentive in leading the charge to connect the care team. When payers are not integrated into care, they don’t have real-time access to care plans and patient information. Everyone on the team (providers, payers, patients, and caregivers) need a comprehensive view to know (1) who is on the team, (2) the plan of care (3) roles and responsibilities, and (4) the state of play.

Previously, payer case managers were siloed and data was retrospective. The ecosystem has changed, however, and by including data-driven payer case managers on the team, providing new real-time process data, and connecting everyone with innovative technology platforms, payers can bring meaningful value to everyone on the team.

Caregiver Relationships

Payers must not only engage members, but also connect with caregivers who are often best positioned to support and facilitate appropriate care.

I have a member of my family dealing with a wide range of challenging medical conditions that are being treated by doctors and nurses in several different practices across multiple specialties. Most of the care activities assigned by these physicians are communicated, facilitated and completed by caregivers in my family – to be carried out in the home.

Our situation is not unique. Four out of ten adults in the US are now caring for a sick or elderly family member as more people develop chronic illnesses and the population ages. More and more care is happening outside of the hospital.

To effectively engage with members, payers must engage with patient caregivers who represent a key resource to drive care.

Coordinating with Providers

Payers are working with provider organizations to establish new care models like accountable care organizations, alternative quality contracts, and patient-centered medical homes to share risk around patient care. We see evidence of demonstrable care and cost improvements when payers and providers coordinate together around patient care. New care models focused on financial incentives, case management and shared data validate improved health outcomes.

This was demonstrated here in New England by a joint initiative between Aetna and NovaHealth. The pilot program with a defined patient population had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide un-managed Medicare populations. NovaHealth’s total costs per member per month, across all cost categories for its Aetna Medicare Advantage members, were 16.5 percent to 33 percent lower than costs for members not in this provider organization.

Specific payer-to-provider alignment can add complexity when provider groups have patients with a range of payers represented in their panels – the key is to identify populations and engage them as meaningful and accountable members in patient care.

Providing appropriate incentives is a key change payers can make to facilitate their broader involvement in care. Over the past few years CMS has introduced new reimburse models with Transitions Care Management (TCM), Chronic Care Management (CCM), and the new Oncology Care Model.

Payers should follow the lead of CMS and provide meaningful incentives that promote coordination and communication. Reimbursement is an important signal payers can make to providers that will foster collaboration and expand the channel of team-based care, demonstrating their value-add to the patient care team.

The Payer Plays on the Team

Payers are seeking opportunities to engage with providers to address the coordination, communications, and costs associated with the most complex care patients – the benefits of doing so have been proven. Team-based care that leverages case managers, innovative tools, and expanded incentives presents a powerful opportunity to change the outcomes associated with new models of care.

This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.