Is case management the same as care coordination?

Coordinating a patient’s care properly can mean the difference in that patient’s healthcare outcomes. The primary care physician, in particular, must be able to coordinate care for patients who are seeing multiple providers, undergoing tests, or staying in healthcare facilities for treatment of chronic or complex illnesses. This type of care coordination is not the same as case management.

The Case Management Society of America (CMSA) defines case management as “provided by healthcare professionals working with people to identify issues and barriers that may prevent them from getting better and uncovering mutually agreed upon solutions to achieve their healthcare goals.”

The Agency for Healthcare Research and Quality (AHRQ) describes care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” The AHRQ emphasizes that care coordination necessitates communicating the patient’s needs and preferences at “the right time to the right people.” The information must be shared and used in a secure manner and in a way that provides “effective care to the patient.”

Care coordination’s main goal, as the AHRQ defines it, “is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care.” Given the shift toward value-based reimbursement structures, independent physicians are investing in tools that help them more effectively direct their efforts toward the specific and immediate needs of their patients.

Similar to and working with the primary care physician’s care coordination efforts, CMSA states that case management is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes.”

Further, case management “helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value” for patient, payer, and provider.

Nick Dealtry
January 28, 2019


Breaking down the major ACO changes from the MSSP final rule

On December 21, 2018, the Centers for Medicare & Medicaid Services (CMS) published its Medicare Shared Savings Program (MSSP) final rule for accountable care organizations (ACOs). The program is now referred to as Pathways to Success and encourages ACOs “to transition to performance-based risk more quickly and, for eligible ACOs, incrementally, to increase savings for the Trust Funds.”

The final rule does away with the previous tracks (Track 1, 1+, 2, and 3) and offers two participation options: BASIC and ENHANCED. Beginning on July 1, 2019, ACOs will enter into agreements under one of these new tracks for at least 5 years.

  • BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk that, at the highest level, would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program
  • ENHANCED track, based on the program’s existing Track 3, which provides additional tools and flexibility for ACOs that take on the highest level of risk and potential reward.

CMS states that one of the goals of the new structure is “Promoting accountability by accelerating the move to two-sided risk while promoting competition by encouraging participation by low revenue ACOs.” Under the Pathways to Success program, ACOs will be classified as “low revenue” or “high revenue.”

  • Low revenue ACOs identified as experienced with performance-based risk Medicare ACO initiatives, such as ACOs identified as having previously participated in the program under Track 2, Track 3 or the Track 1+ Model, are restricted to participating in either the BASIC track’s highest level of risk and reward or the ENHANCED track.
  • High revenue ACOs determined to be inexperienced with performance-based risk Medicare ACO initiatives would be limited to no more than a single agreement period under the BASIC track. High revenue ACOs determined to be experienced with performance-based risk Medicare ACO initiatives would be restricted to participating in the ENHANCED track.

CMS is offering an application cycle for a one-time new agreement period start date of July 1, 2019, and will resume the usual annual application cycle for agreement periods starting on January 1, 2020, and in subsequent years.

Nick Dealtry
January 22, 2019


Value-based care and care management

Value-based care, as opposed to fee-for-service care, has been shown to improve the quality of care management, particularly for those patients with one or more chronic conditions. Those are the findings of a recent study conducted and published by Humana, the Value-based Care Report.

Worthe Holt Jr., M.D., M.M.M., Humana V.P., Office of the Chief Medical Officer, writes in the report that “By integrating care at all levels, we can better coordinate prevention and wellness of populations to slow and prevent the advancement of disease. We are rapidly moving from a focus on episodic care to one that addresses the whole person, inside and outside the clinical setting, by practicing value-based care.”

The study, Humana’s fifth annual, found that “Physicians who practice value-based care are achieving higher rates of patient engagement in preventive screenings, medication adherence and management of chronic conditions as measured by HEDIS (Healthcare Effectiveness Data and Information Set).”

Value-based care and care management are connected in that physicians are more focused on the need for preventive care and chronic condition management in a value-based care setting. They are better able to manage care for their patients, particularly those who may face challenges with social determinants of health, such as food insecurity or other socioeconomic factors, and who may also tend to experience more chronic conditions.

In fact, the report stated, that “on average, Americans with five or more chronic conditions spend 14 times more on health services than people with no chronic conditions.” Proper care management, including preventive care and medication management, that is part of a physician’s value-based care plan for the patient can catch these conditions early and enable the physician to properly treat the patient, keeping the patient healthier.

Roy A. Beveridge, M.D., Humana’s Chief Medical Officer, stated that “Practicing value-based care works to address the nation’s chronic disease epidemic by giving physicians the support and data they need to focus more on prevention and reduce acute care episodes. This model allows physicians to focus time and energy on those patients who need the most support to stay well at home, and out of the hospital. Physicians are clearly seeing the benefit of improved patient outcomes and more shared savings.”

Nick Dealtry
January 18, 2019


Why a patient longitudinal record is important for ACOs

The Accountable Care Organization (ACO) is a Centers for Medicare & Medicaid Services (CMS) Innovation Model. CMS defines ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve.” Coordinated care is an important aspect of the ACO, as it “helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.”

The Health Information and Management Systems Society (HIMSS) emphasizes that “once an accountable care organization (ACO) or other collaborative care entity has laid the foundation for a robust health data exchange by ensuring the electronic capture of complete clinical and financial information at the individual provider level, the next step is to build the core of the structure – the longitudinal patient record.”

A longitudinal record holistically evaluates patient population with a record that trends vitals and lab values over time. The move toward longitudinal records is key to understanding a patient’s complete medical picture. Access to and use of longitudinal records is particularly important for patients with chronic conditions, as the independent physician can quickly access important clinical data to help manage chronic conditions and easily schedule follow-up appointments to address any potential gaps in care.

Patients with chronic conditions tend to see multiple providers, undergo lab tests, and may require stays in healthcare facilities. Coordinating that care within the ACO relies on the patient longitudinal record being accurate, current, and easily accessed by each provider. HIMSS explains that “in addition to providing support for clinical decisions, longitudinal records included in the ACO’s central data repository enable the organization to monitor compliance with treatment guidelines, meet reporting requirements and identify best practices to improve care.”

Nick Dealtry
December 14, 2018


Health information exchanges (HIEs) and interoperability

The ability to share patient data is critical for the independent physician to provide value-based care for that patient. When a patient sees specialty providers or undergoes lab tests, the primary care physician must have the visit notes and test results to provide appropriate, effective care. Exchanging information electronically is much more efficient than sharing patient data on paper, either hand delivered or via fax.

Physicians who use electronic health records (EHRs) can take advantage of the electronic sharing of patient information between different EHR systems and healthcare providers, improving the ease with which doctors can provide care to their patients and patients can move in and out of different care facilities. This electronic sharing through EHRs is referred to as interoperability, a vital piece of the accurate and timely transmission of patient data between EHR systems.

Health information exchange (HIE) enables that interoperability to happen. As the Healthcare Information and Management Systems Society (HIMSS) describes it, interoperability involves an exchange of patient data that can be viewed and understood on both ends. Interoperable EHR systems “must be able to exchange data and subsequently present that data such that a user can understand it.  In order to ensure interoperability, the use of standards enable data to be shared across disparate healthcare settings regardless of the application or vendor.” HIE, explains the HIMSS, is a “a dynamic and evolving landscape … critical for successful healthcare reform, enabling interoperability and meaningful use of health information and technology.”

The Office of the National Coordinator for Health Information Technology (ONC Health IT) further explains that HIE “allows health care professionals and patients to appropriately access and securely share a patient’s medical information electronically. There are many health care delivery scenarios driving the technology behind the different forms of health information exchange available today.”

Health IT states that “sharing electronic patient information enables providers to:

  • Access and confidentially share patients’ vital medical history, no matter where patients are receiving care—specialists’ offices, labs, or emergency rooms
  • Provide safer, more effective care tailored to patients’ unique medical needs.”

Interoperability between EHR systems, powered by HIE, would make health care data universally sharable, facilitating patient care, and allowing for seamless referrals and transitions between healthcare providers.

Nick Dealtry
December 10, 2018


Questions to ask about interoperability during EHR purchasing decision

As the National Academy of Medicine (NAM) has recently published a report on the need to drive interoperability between electronic health records (EHRs), many healthcare providers may be asking how to purchase an EHR solution that enables that critical interoperability. An EHR Intelligence article has outlined a number of questions to be asked during the purchasing decision.

Those questions include:

  • Does the EHR vendor adhere to industry standards?
  • Does the EHR vendor work with interoperability services providers?
  • Does the EHR product’s level of interoperability align with organizational needs?

There are resources available to determine the answers to some of these questions. For example, the Office of the National Coordinator for Health Information Technology (ONC) provides information about vendors that meet the 2015 Edition Health IT Certification Criteria for certified EHR technology (CEHRT). In addition, ONC provides information about which vendors use the Fast Healthcare Interoperability Resources (FHIR), a specification for exchanging clinical and administrative health care data. Healthcare providers can also include these questions in their requests for proposals (RFPs) issued to EHR vendors during the purchasing process.

Interoperability is critical for the exchange of information between healthcare providers and is particularly beneficial to care managers in their work in coordinating care for patients. Care managers have been shown to be effective particularly in the care of patients with complex or chronic conditions. However, a 2016 study on care coordination and interoperability “identified multiple areas where the lack of interoperability leads to inefficient processes and missing data” and found that “significant care coordination gaps exist due to the lack of interoperability across the United States.”

The NAM publication emphasizes that “Digital interoperability across clinicians, care units, facilities, and systems has become more essential because of increasing complexity in health care, the need for more seamless interfaces among clinicians, patients and families, and the growing number of clinicians across disparate specialties that a typical patient sees.”

Asking the right questions during the purchasing process can result in EHR interoperability benefiting the independent physician, the case manager, and most importantly, the patient.

Nick Dealtry
November 29, 2018


How to integrate a cost-benefit analysis with value-based care

The move toward value-based care has caused independent physicians to move from a fee-per-visit model to payments based on quality healthcare outcomes for their patients. The trend has created a situation for many independent practices in which they need to be more efficient, particularly in regard to costs for treatment that may not be immediately reimbursed. A cost-benefit analysis integrated with the physician’s value-based care model may help in that area.

Research recently published by Joel Tsevat, MD, MPH, professor of medicine at UT Health San Antonio, calls for a “convergence” of cost-benefit analysis and value-based healthcare. Tsevat has identified the key differences in the two as being time, perspective, and the ability to maximize outcomes.

While value-based care focuses on shorter timeframes, such as a 30-day plan of care, cost-effectiveness analysis tends to look at the longer term, often as long as a patient’s lifetime. Cost-effectiveness analysis, viewed from a more societal or health care sector perspective, can actually benefit from “drawing on value-based healthcare’s patient-centered approach,” Tsevat says. Conversely, “value-based healthcare could benefit from the capability of cost-effectiveness analysis to gauge tradeoffs—the costs for the benefit.”

In the research report, Tsevat states that “Value-based health care focuses on maximizing outcomes achieved per dollar spent. As such, it bears many similarities to a well-established method, cost-effectiveness analysis (CEA), which provides a framework for comparing the relative value of different diagnostic or treatment interventions.”

Understanding the cost-effectiveness analysis could become a critical component of efficiency and financial stability for the independent practice. Value-based care will be rewarded, but the independent physician must gauge the costs and weigh them against the returns. As Tsevat emphasizes, “value-based payment has emerged as a visible component of VBHC (value-based healthcare) and is gaining a foothold in the United States in various forms, particularly bundled payments and accountable care organizations, in an effort to reward high-value care and disincentivize low-value care.”

Nick Dealtry
November 14, 2018


The core tenets of a care management system

In the move to value-based healthcare, care management is gaining traction as a way to effectively and cost-efficiently manage the health of the independent physician’s population of patients. The renewed focus on what has been termed the “Triple Aim,” that is, sustainable costs, better health outcomes, and improved patient experience, has led to the need to implement a care management system for managing patients and their plan of care.

A brief published by the Agency for Healthcare Research and Quality (AHRQ), “Care Management: Implications for Medical Practice, Health Policy, and Health Services Research,” defines care management as a “team-based, patient-centered approach” to helping a population of patients and their support systems to manage their medical conditions more effectively. Care management also “encompasses those care coordination activities needed to help manage chronic illness.”

Care management systems should incorporate data analysis capabilities as well as practical aspects of patient engagement and care coordination. The system should also define “patients beyond their diseases,” according to Ron Geraty, MD, writing for HIMSS. Dr. Geraty states that “care plans that are based solely on disease can be ineffective, contribute to resource waste, and fail to deliver appropriate interventions.”

Patient segmentation is an integral part of a care management system as well. As Dr. Geraty explains, “Segmentation zeroes in on clear steps to advance the Triple Aim across a spectrum of clinical conditions, and interventions are delivered with precision to those who need them the most.”

The three strategies for an enhanced and effective care management system highlighted in the AHRQ brief are to “1) identify population(s) with modifiable risks; (2) align CM services to the needs of the population(s); and (3) identify, prepare, and integrate appropriate personnel to deliver the needed services.”

In a theme similar to Dr. Geraty’s, AHRQ recommends that a care management system should first identify and develop “risk-based approaches to identify patients most in need of care management (CM) services. As part of the process in developing an effective care management system aligned to the specific needs of the patients, AHRQ also recommends using electronic health records (EHRs) “to facilitate care coordination and effective communication with patients and outreach to them.”

Nick Dealtry
November 12, 2018


ACOs and more advanced risk-taking models

Accountable care organizations (ACOs) that participate in the Medicare Shared Savings Program (MSSP) take on a certain level of risk, depending on the track they choose. There are three track levels, each with an increased amount of risk involved. Most ACOs choose Track 1, which has the lowest level of risk. In fact, in 2018 there are 561 Medicare ACOs in the program and 82% of them remain in Track 1.

The Centers for Medicare & Medicaid Services (CMS) recently implemented a Track 1+ as a time-limited CMS Innovation Center model. An ACO must concurrently participate in Track 1 of the Shared Savings Program in order to be eligible to participate in the Track 1+ Model. The Shared Savings models are currently:

Track 1 – Track 1 ACOs do not assume downside risk (shared losses) if they do not lower growth in Medicare expenditures.

Medicare ACO Track 1+ Model – Medicare ACO Track 1+ Model (Track 1+ Model) ACOs assume limited downside risk (less than Track 2 or Track 3).

Track 2 – Track 2 ACOs may share in savings or repay Medicare losses depending on performance. Track 2 ACOs may share in a greater portion of savings than Track 1 ACOs.

Track 3 – Track 3 ACOs may share in savings or repay Medicare losses depending on performance. Track 3 ACOs take on the greatest amount of risk but may share in the greatest portion of savings if successful.

According to CMS regulations, ACOs that began in Track 1 in 2012 or 2013 must move to a risk-based model by their third contract periods, which begin in 2019. A National Association of ACOs survey found that 71% of the ACOs that began their MSSP participation in those years are “likely to leave the MSSP if they must assume risk.”

The Association has asked CMS to consider revising its regulations, allowing ACOs to continue their participation in Track 1 an additional three years. Over two-thirds of the Association’s survey respondents said they would remain in the MSSP if the changes were made. The ACOs say “they need more time without risk because MSSP regulation has changed considerably since the early years and ACOs are just now operating successfully.”

Nick Dealtry
November 5, 2018


Understanding the social determinants of health and how they impact population health

A patient’s health status can be impacted by many factors, including genetics, eating habits, and physical activity (or lack thereof). There are a number of other factors that can affect a patient’s health as well, which cannot necessarily be treated with medications or traditional care plans. Social determinants of health are, according to the World Health Organization (WHO), “the conditions in which people are born, grow, live, work and age.”

For patients, social determinants of health, “circumstances (that) are shaped by the distribution of money, power and resources,” can influence their food choices and even whether they have access to quality healthcare. Social determinants include “intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.”

For healthcare providers, social determinants of health affect decisions made for population health management. The physician must take into consideration whether patients can afford to eat healthy foods, fill their prescriptions, and follow other plans of care that may be out of their range either financially or logistically. True value-based care can involve collaborating with community organizations and social service agencies to gauge needs and provide appropriate care based on the patient population’s circumstances.

The “complex interactions and feedback loops” of social determinants of health, as described in a recent article in NEJM Catalyst, include “poor health or lack of education (that) can impact employment opportunities which in turn constrain income. Low income reduces access to healthcare and nutritious food and increases hardship. Hardship causes stress which in turn promotes unhealthy coping mechanisms such as substance abuse and overeating of unhealthy foods.”

Value-based care for these populations will depend on the physician understanding the social determinants of health for the patient group, including the economic environment, employment opportunities, access to safe drinking water, and availability of quality food choices. Maintaining detailed patient data in electronic health records (EHRs) can help the physician track and manage the population health of patients who are impacted by these social determinants of health.

Healthcare professionals have available significant “data and research which indicates that the social determinants of health have a higher impact on population health than healthcare and that a higher ratio of social service spending versus healthcare spending results in improved population health.”

Roy Steiner
October 29, 2018