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:
What are the requirements of a successful CM team? These would be:
These are the requirements in an inpatient setting:
On an outpatient setting, these are the requirements:
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.