Integrated care management promises great beneits for patients, providers and payers, but requires disciplined planning and execution.
Health care is on the everyone’s mind in the United States. That preoccupation is fueled in part by the controversy surrounding the Patient Protection and Affordable Care Act, which promises to ensure coverage for 32 million Americans currently without health insurance. But the conversation on health care also is driven by the country’s changing demographics, particularly the aging population bubble—known collectively as the baby boomers—that threatens to overwhelm health care providers and payers with increasing and prolonged demands.
That threat is exacerbated by the fact that medical care in the United States today suffers from problems related to cost, quality, fragmented delivery, and compliance with new models and reforms. Other significant challenges include a lack of coordination among physicians, concern for patients’ positive experiences in the health care system, and accessibility to widely dispersed medical records.
Providing health care for the elderly and the chronically ill population is a key challenge, since this group is where the bulk of the cost of health care is generated. Based on industry estimates, payers and providers could spend $15 billion to $20 billion over the next decade on advanced care management. The nation’s health care delivery system, beset with its own array of challenges, is unable to support the personalized care goals and outcomes that are important to patients. Since the health care system is reactive, it cannot reduce the need for expensive medical services and hospitalizations.
There is a need for a next-generation model for care management that is proactive, integrated, patient-centric and outcome-based to provide the best care and most effective management of chronic diseases, post-acute care, and complex health and social care needs.
Problem areas for payers and providers include controlling costs as well as improving the quality and coordination of care delivery and the potential for dramatic change brought on by regulatory reforms.
Impact of Reforms: Evaluation of New Delivery Models
The Patient Protection and Affordable Care Act calls for the creation of an Accountable Care Organization (ACO) program administered by Centers for Medicare and Medicaid Services (CMS) by January 2012. Qualifying providers, including hospitals, physician group practices, networks of individual practices, and partnerships between hospitals and other health care professionals, are eligible to form ACOs. ACOs become accountable for the quality, cost, and overall care of the Medicare fee-for-service bene!ciaries assigned to them. They will also be expected to meet speci!c organizational and quality performance standards to be eligible to receive payments for shared savings.
The National Committee for Quality Assurance (NCQA) recently announced a technical speci!cation that any health care organization looking to show ACO readiness must meet. “Releasing these measure speci!cations is also an important step in making ACOs a functioning, vibrant part of American health care,” said Mary Barton, Vice President of Performance Measurement, NCQA1.
The new ACO accreditation measure adds patient-centered primary care, access to needed providers, and patient rights and responsibilities to the already established criteria. ACOs are looking to meet this accreditation measure and dovetail with the outcomes available through the sophisticated use of IT.
On the other hand, CMS’s star ratings provide an opportunity for health plans to earn huge bonuses by improving the scores in the 53 performance measures speci!ed by CMS. By implementing new IT systems, health plans can track their performance in the speci!ed measures.
Efficiency and integration are inherent in the use of IT, which offers health care providers and payers capabilities that contribute to lower costs and higher quality of service while giving patients the control of their care and easy interaction with their physicians that they seek. “We need to incentivize both providers and patients for better health outcomes, which is the key for success of ACOs,” says SasiKanth, Associate Consultant with Wipro Technologies.
The Five Building Blocks of Integrated Care Management
Integrated Care Management
Integrated care management is a process whereby an individual’s needs are assessed and evaluated, eligibility for service is determined, care plans are implemented, services are provided, and needs are monitored and re-assessed.
Next-generation technologies enable care delivery through integrated care management to be fast, secure, and affordable. Integration with analytics, customer-relationship management, remote patient monitoring, online collaboration tools, and mobility ensures the right care for the right person at the right time. It seeks to change the nature of health care from reactive to proactive, from fragmented to coordinated, and from static to dynamic.
Integrated care is the key to improving quality outcomes for the most frequent and costly care for the elderly and patients with chronic conditions. Integrated care management works on !ve major building blocks:
- Analytics. Integrated care management simpli!es the process of integrating information from diverse sources and systems, including claims, eligibility, lab results, health risk assessments, personal health records, and care management. It uses predictive modeling to help organizations to stratify members and group them in categories based on the level of criticality of care needed.
- Collaboration. Online collaboration among constituents—the patient, the physician, and the care coordinators—using SMS, chat, voice, and video for patient health assessment, clinical report diagnosis, e-appointments, e-consultations and e-prescriptions enables anywhere, anytime care for patients.
- Interoperability. Because integrated care management approaches the patient from the perspective of a whole person, it demands that disparate, distributed systems can work together to share information and data. Therefore, technology interoperability is a key element of these strategies.
- Portability. The ability for the patient and his or her physicians to interact quickly, easily, and around the clock requires technology that is portable among different systems and can interact with various end-user devices. Mobility enables on-the-go access to health records and availability throughout the encounter.
- Security. Privacy and security are two of the most critical and compelling initiatives within the health care community today. Due to the multiple parties and various input and access points, privacy and security are even more important in the integrated care management environment. As with any process or project that involves IT integrally, focus and proper direction are vital for success. That’s why health care organizations bene!t from seeking the help of an experienced partner for their next-generation health care initiatives.