What You Want to Know About Care Coordination in the PCMH


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Last week we conducted our latest medical home-related webinar “Going Beyond the EHR—Supporting Care Coordination Within the Patient-Centered Medical Home.” Attendance was great, and even better, we received a lot of really good follow-up questions. I thought I might share some, along with my responses to them, as a way of continuing the discussion and providing further insight. Here’s a sampling:

Q: Do you think that ACOs could drive down healthcare costs if they contract directly with large employers and put pressure on health insurers to reduce premiums? And, do you believe that ACOs will aggressively market their models to employers?

A: In that scenario they might be able to drive down premiums but not necessarily the overall cost of healthcare. There are some opportunities for ACOs to contract directly with employers, particularly if it’s with several large organizations whose employee bases are mostly centrally located. Otherwise the model won’t be sustainable. The other concern is that by excluding health insurers, you’re also excluding their competencies, tools and information—paying claims, analytics, reporting, managing risk, etc. Time will ultimately tell.

Q: Hospitals will be penalized for readmissions. What is the penalty that would be assessed to an ACO if they are involved in the 30-day follow-up care and the patient readmits?

A: As a software solution company, our primary focus is on providing technologies that make the whole process transparent and easily understood so that reimbursements can be planful and not surprising to anyone. The actual reimbursement and the penalties and rules around how it is administered will likely be a very customized process, at least for quite some time. However, the likelihood is that the readmit will happen but that the ACO/hospital will simply not be reimbursed for the additional care.

Q: What is the implication for clinical decision support’s value based on your comment?

Note: The questioner is referring to a slide I showed during the presentation indicating that the addition of an EMR and clinical decision support tools, even if reimbursement supported it, does not alone generate higher quality or greater adherence to evidence based protocols.

A: There’s tremendous value for clinical decision support as a tool, but not if we expect already-overextended physicians to add it to their normal workloads. We’re advocating a reimbursement model that requires clinical practices to add dedicated staff to proactively pursue improved outcomes through clinical decision support that provides a complete view of patient activity and facilitates population management instead of today’s patient-specific approach. These staff members should be clinicians with the ability to manage a care plan once the patient becomes engaged. Population management, medication reconciliation, and care plans should be for nurses using tools we’re planning to provide. Diagnosing and treating patients and overseeing all clinical activities should be what physicians do, probably using the EHR.

Q: What exactly is the difference between (the) medical home and case management programs?

A: One major difference is where it’s performed. In the medical home, case managers generally administer care plans within the physician’s practice, whereas today this is most often performed by the health plan or a person at the hospital focused very specifically on one episode of care. The medical home care coordinator shares the same physical location in which patients are being diagnosed and treated. They’re not just suggesting a plan; they’re also in a position to implement it. Today, most case management that occurs outside of the physician setting works very much in a silo, and the physician has very little involvement or knowledge of it. In the medical home, the care coordinator is part of the physician’s care team. They will be involved in more tactical aspects of the care plan, meaning if evidence shows that a patient needs a test, the coordinator might actually contact the lab tech and have it scheduled on the spot. It’s not as if this doesn’t happen when doing case management over the phone, but the nature of where it happens in the medical home setting makes that call more likely to happen. This fosters stronger adherence, since physicians generally wield a high degree of influence with patients.

MEDecision’s vision anticipates that the medical home care coordinator will need to work very collaboratively with the care manager at the health plan for quite some time. We can’t expect one care coordinator in a panel with a high percentage of co-morbid patients to handle every aspect of case and disease management. They’ll need to share some of this work. This only succeeds if each side can see each other’s updates to the care plan, which we’re planning to enable.

Q: What do you mean by your reference to health information exchanges?

A: Our Nexalign® platform offers the capability to build health information exchanges, either at the government level or at the smaller and private ACO level. We feel that this is a foundational component for medical homes, and ACOs in particular. It’s something we could implement today even if a customer didn’t purchase any of our other products. We’re already seeing payers purchasing HIE services for their most strategic medical homes in order to show value as a partner and, of course, to enjoy the savings associated with information sharing. I felt this made it relevant to include as a summary item and to show that you don’t have to be a major, national health plan to do these kinds of things.

As you can see, we had some really interesting questions. I hope you found the answers helpful. This conversation is the perfect lead-in to MEDecision’s plans for HiMSS next week, including our sponsorship of the 6th Annual HiMSS Payer Networking Breakfast. This year’s event will focus on ACOs, their implications for improving the cost and quality of care and the essential role that technology will play in their success. I hope to post an update on the event here at some point soon, so check back.

Matt Adamson
Matt Adamson is vice president of medical home initiatives for MEDecision, a leading provider of collaborative health management solutions. Mr. Adamson is currently responsible for defining the vision and strategy for MEDecision's medical home products and services, representing MEDecision with stakeholders interested in furthering the medical home movement in the U.S. Learn more about MEDecision at www.MEDecision.com. Follow the company on Twitter at @MEDecision and on Facebook at www.MEDecision.com/Facebook.


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