.jpg "Daniel Godla")
Care management service providers—the companies to which physicians and their practices outsource their programs—are becoming increasingly popular.
This growth comes from providers launching internally staffed programs and realizing it’s beyond their bandwidth. Or, they struggle with scaling their program or managing the process and billing.
Alternatively, some organizations want to start new programs, but they’re unsure whether it’s worth the investment and staffing. Others use outsourcing to pilot a new service and test whether they wish to develop their own.
In each situation, it’s crucial to understand the potential benefits of outsourcing care management. Providers should have an approach for thoroughly vetting a care management service organization.
Benefits of outsourcing care management services
There are numerous benefits to implementing a Chronic Care Management (CCM) program.
1. Reduced workload for physicians and staff
Outsourcing can free up physician and staff time by reducing administrative burden.
Service organizations enable clinics to focus on in-office patient care rather than coordinating CCM logistics. Working with additional professional staff can also extend CCM to a larger population.
2. Faster implementation and scalability
A care management service company can launch a program quickly compared to what may be required in-house, starting fresh. A capable third party already has the necessary processes and technology in place, reducing time-to-enrollment.
Additionally, outsourced services should ensure seamless program expansion without quality compromise. These companies are staffed to support large patient populations.
3. Access to specialized expertise
Care management service providers can offer highly skilled care coordinators experienced in managing various chronic conditions and working collaboratively with patients. Since they focus exclusively on care management, they can be well-versed in best practices for running successful programs.
4. Compliance and documentation support
Care management companies are typically up-to-date on relevant regulations and support strict adherence.
A critical focus is on maintaining accurate documentation and submitting Medicare reimbursements.
Taking responsibility for billing and documentation supports a compliant program without adding extra work to the physician or clinic staff.
5. Improved patient outcomes and engagement
Technology, clinical services, and data analytics can enhance patient engagement between office visits. Care management can increase patient compliance with care plans, improve health outcomes, and reduce hospitalizations.
It also adds another layer of oversight through monthly patient contacts, progress tracking, and continuous communication with healthcare teams.
6. Cost-effective resource optimization
Outsourcing allows clinics to optimize their internal resources. It decreases the need to hire and train additional staff, thus lowering overall operational costs.
Providers also avoid other expenses, such as new technology platforms and infrastructure, that the outsourced vendor bears.
7. New revenue stream and greater potential for shared savings
Outsourcing CCM can generate significant financial returns. Some estimates suggest managing 100 patients a year can yield $80,000 in new service revenue.
At ThoroughCare, we recommend that our provider clients manage about 250 patients per assigned care manager. With 250 enrolled patients, the practice could generate between $150,000 and $352,500 in gross revenue annually before deducting the service provider’s percentage or fee.
Plus, many CCM service companies do not charge upfront costs and instead split Medicare reimbursements with the clinic.
What to consider: How to evaluate a care management service company
Assessing a potential third-party care management service provider can be daunting. There are several critical areas to consider, along with our recommendations on what to look for and what to avoid.
Armed with these, providers can assess the best fit between the clinic’s needs and the vendor’s offerings.
1. Clinical and non-clinical team experience
It’s vital to vet the firm’s experience and the certifications held by the staff who will have direct contact with patients.
- What are care managers’ qualifications and limitations?
- What is the appropriate level of care or risk that merits escalation, and to whom?
A designated person on the internal care team is accountable for CCM activities—whether outsourced or in practice.
2. CMS compliance oversight and documentation
In addition to confirming clear and appropriate responsibilities with patients, explore the firm’s experience and competence with policy requirements, such as from the Centers for Medicare and Medicaid Services (CMS). This includes eligibility, documentation, service delivery, and billing.
3. Types of care management programs offered
What breadth and depth of care management services are offered? Chronic Care Management should be provided at a minimum.
- Do they offer Principal Care Management (PCM), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), or other Medicare care management programs?
- How are the client’s patients spread across these programs?
4. Technology, software, and data sharing
Learn what specific software platform they use for managing patients and their care management programs.
Can you receive a demo? Look for essential features, such as:
- Checklist to ensure program requirements are met
- Workflow management
- Time tracking, where required, and automated documentation
- Evidence-based assessments and care plans
- Robust data analytics and reporting
- Data sharing and interoperability with customer EMRs
- Patient population management and tasking
- Patient communication options – telephone, portal, secure texting, email
- Billing oversight and accuracy
Look for how the software uses artificial intelligence to automate and streamline documentation, pre- and post-patient contact notes, and auto-generate next steps.
5. Operational standards and policies
In addition to staffing and software, it’s vital to understand the operational standards that underpin the program’s outreach and patient engagement.
- What techniques and patient-centered approaches do they use, and how often?
- Additionally, what documented success have they had with these tactics?
- Do they have any client case studies that demonstrate improvements in engagement, health outcomes, and patient satisfaction?
- Where do they have a proven track record?
6. Evidence-based, personalized care planning, assessments, and education
- What evidence-based tools and strategies are they using, and from what healthcare organizations or research are they looking for expert guidance?
- Are they competent in motivational interviewing, and are they using validated patient assessments, such as a health-related social needs screening tool?
- What clinical resources do they have internally to stay on top of quality improvement?
- Can they create or integrate tailored assessments that may be unique to a particular practice and their patients?
- What patient education resources does the software integrate?
- Is it evidence-based, current, multi-lingual, and appropriate for patients’ literacy levels?
7. Dedicated staff-to-patient ratio
A care manager regularly engaging a patient is key to building rapport, knowledge, and trust.
- Does this service provider have a dedicated care team to monitor patients?
- Do they assign care managers to follow one patient’s care consistently over time?
- What is the care manager and general staff turnover rate?
8. Communication and collaboration
- How and how often will leadership communicate with each customer?
- Do they provide regular reports and opportunities to review program output and results, as well as discuss ways to improve?
- What do they consider poor vs. expected results at different phases of the program?
- What levers are available to improve outcomes?
9. Billing, fees, and contracts
The financial agreement between the care management service company and the provider is critical. The same is true for the economic health of the program.
- What are the vendor’s fees and contract terms?
- Is there a flat per-patient, per-month fee for minimum deliverables, or do they charge a percentage of the billing fee?
- Are the charges flexible as patient enrollment changes?
- How long is the required contractual commitment, and what are the terms for canceling the contract?
- Are there a la carte fees charged for additional services?
- How does the vendor document that they’re regularly meeting their contractual requirements?
- Do they have any stake in ensuring the program’s success?
- What support does the vendor provide if CMS audits the program?
- Is this support an additional cost?
Case study shows care management's benefits
Since 2017, MetaPhy Health has assisted GI providers with care coordination, supporting clinicians in managing complex diseases, and utilizing data to mitigate risk.
ThoroughCare helped MetaPhy Health implement and scale Chronic Care Management and Remote Patient Monitoring to more than 24,000 patients.
Through robust analytics and reporting, MetaPhy Health tracks key performance metrics to inform management and care decision-makers. The company supports its clients in managing complex diseases.
ThoroughCare’s group functionality features help enable MetaPhy Health to seamlessly support multiple sites and patient populations. The software helps facilitate operations across the entire healthcare organization, as well as individual care sites or office locations.
Care management service providers use ThoroughCare
ThoroughCare gives care management service companies the foundation for delivering effective, patient-centered care coordination. We help companies follow best practices.
ThoroughCare offers a comprehensive software platform, featuring evidence-based tools, data analytics, time tracking, and communication between teams and patients. Create, enroll, and engage new populations and stand up new programs quickly.
Everything a service provider needs to deliver high-quality care is available with ThoroughCare.
Key questions answered
What are the benefits of outsourcing care management services?
There are numerous benefits to outsourcing a Chronic Care Management (CCM) program, including:
- Enable a new service for patients without additional staff
- Implement and scale a care management program faster
- Improve patient outcomes and engagement
- Offer greater value to patients
- Generate new streams of revenue with a greater potential for shared savings
What are the key areas to evaluate when assessing whether to outsource care management services to a third-party vendor?
There are several critical areas to consider when vetting a potential care management service company, including:
- Clinical and non-clinical team experience
- CMS compliance oversight and documentation
- Types of care management programs offered
- Technology, software, and data sharing
- Operational standards and policies
- Evidence-based and personalized care planning, assessments, and education
- Dedicated staff-to-patient ratio
- Communication and collaboration approach
- Billing, fees, and contract aspects