Increased economic pressures squeeze health plans, and providers seek relief from burnout and revenue loss while wanting to improve outcomes. Both parties are looking for ways to achieve cost reductions, enhance quality, and better the healthcare experience.
In a previous article, we examined how payor-enabled, provider-delivered Chronic Care Management is expanding. We presented McKinsey’s research on four strategies to maximize ROI. Here, we will examine how care management programs support greater collaboration between payor and provider organizations toward shared imperatives.
Payors are shifting their care management strategy
Research shows that all health plans offer care management programs regardless of size, location, and ownership. And, while these payors’ “internal evaluations suggest that interventions improve care and reduce cost, plans report difficulties in engaging members and providers.”
According to the 70-plus health plans surveyed for a study by the American Journal of Managed Care (AJMC), anywhere from 56% to 96% of health plans offer supplemental health services, including:
- 96% offer coordination with social care
- 92% offer medical care coordination
- 60% offer home assessments
- 56% offer home visits
Traditionally, health plans have used risk stratification to determine candidates for three interventions: health promotion and wellness for low-risk members, disease management for medium-risk members, and case management for high-risk members.
However, risk stratification is not the sole approach that payors use to identify which members should be engaged in care management.
Addressing comorbidities through care management programs
According to McKinsey, the increasing prevalence of physical, behavioral, and comorbid chronic conditions since the COVID-19 pandemic has exposed the need for more holistic and comprehensive team-based care models. This has led payors to rethink how they approach care management.
Care management programs, such as Chronic Care Management, Transitional Care Management, and Behavioral Health Integration, provide an evidence-based approach to care for high- or rising-risk members. These programs can place greater focus on overlapping conditions or complex social risks.
With payors spending 10% or more of their administrative budgets on care management, they are looking to take their investments further. They are looking for proven ways to bend the cost curve while engaging members and providers more deeply.
Three strategies that health plans are deploying all focus on tighter provider engagement, including:
- Integrating care management programs into provider workflow
- Collaborating with providers on care redesign
- Leveraging patient support technologies
Provider collaboration is central to cost, quality, and access goals
Care management collaboration to control cost
According to PwC’s annual report, titled Behind the Numbers, health plans are responding to inflationary and increased provider negotiation pressures by advancing care management.
They report that national health plans demonstrated better cost management and achieved lower cost trends through care management. Health plans are using a variety of methods to build a network of pro-care management providers by offering:
- Data and reporting on care gaps
- Payment incentives
- Clinical design support tools
- Care management technologies
- Practice redesign support
Greater partnership can also facilitate needed alignment between care management and utilization management. One study found that a collaborative, interdisciplinary approach to care management reduced emergency department visits by 16.7% and hospitalizations by 17.7%.
Care management collaboration to improve quality
Tighter alignment between payors and providers maximizes the value of member data. Shared care management programs capture information about member engagement, care gaps, and individual patient care plans.
When data is shared and used strategically through collaborative care management, both payors and providers can provide a united front in addressing member needs. They can deliver quality improvements and achieve performance goals.
Additionally, health plans and providers can each utilize available resources to provide symbiotic support, coaching, and education.
A payor may have very effective wellness coaching, while providers may support excellent nurse practitioners. Both may offer care managers to facilitate individual patient goal-setting and action planning.
Care management collaboration to improve access
Both payors and providers can create standalone care management programs.
However, when developed in collaboration, they can maximize the member’s access to convenient, high-quality care. Health plans may offer a 24-hour nursing line, while primary care providers may offer telemedicine care or after-hour clinics.
Through collaborative care management programs, health plans and providers can support members across the care continuum – from convenient care access and coordination of specialist care to disease education, self-management strategies, and community referrals.
Care management collaboration to improve experience
Health plans are transforming their care management programs toward a more holistic approach that engages providers. Part of the goal is to leverage their strengths, combined with the physician-member relationship, to more deeply guide their care trajectory.
According to the AJMC study referenced earlier, up to 92% of health plans offer incentives exclusive to their care management program enrollees, including:
- 92% offer merchandise or gift cards
- 75% offer lower cost-sharing requirements
- 75% offer lower insurance premiums
- 58% offer discounted gym or health club memberships
- 58% offer value-based insurance design
- 42% offer cash payments or bonuses
Care management can play a vital role in improving member experience, as well as supporting progress towards personalized goals.
ThoroughCare supports payor-enabled, provider-delivered care management
Technology is the foundation of payor-provider partnerships, particularly for dynamic care management programs.
ThoroughCare’s shared technology platform enables integration with electronic health records, health information exchanges, remote monitoring devices, and advance care directives, supporting an inclusive view of member data.
Data analytics reveal member health trends and outcomes, facilitating more accurate risk assessment, cost management, and the promotion of evidence-based care practices.
ThoroughCare helps payors and providers enhance communication, align policies and incentives, and engage members with preventative, personalized care.
