In order to manage the financial risks of being “accountable” to a population, provider organizations that want to be ACOs will have to do five things:
1) assess their assigned members’ individual risk (using health risk assessments (HRAs) and predictive modeling,
2) that then segment or stratify the population into three “buckets”: high, medium and low. Then….
3) deploy a full spectrum of communication interventions, including telephone, mail, email and social media, the purpose being to…..
4) recruit patients into the appropriate care pathways that are tailored to the level of risk. Patients at highest risk need case management. Patients at lower levels of risk may require less intense coaching, such as preventive counseling, telephonic reminders and, if available, wellness interventions. Patients with a high level of readiness to change are most likely to benefit. The purpose of all this is to…
5) apply evidence-based medicine and guidelines using shared decision making so that patients can reconcile the the care they need with what they want and, simultaneously, reduce claims expense (an example is here).
And who is responsible for all this you ask?
Many naive policymakers, out-of-touch regulators, inflexible legal experts and physician-leader apparatchiks will tell you the primary doctors will do it. According to this policy-insider elite, giving PCPs electronic records, 10% pay increases and medical home status will unleash the physicians’ hidden lust for becoming accountable. They’ll want to counsel patients in the course of their office visits.
Poppycock, says the DMCB. Docs don’t mind being ultimately responsible, but they have little interest in reviewing, recruiting or educating lists of patients. They’re more than happy to “outsource” that job to case managers. The DMCB thinks of these professionals as the ones who review the lists, oversee recruitment rates, provide counseling services and assure that maximum numbers of patients become engaged in their self care. Plenty of those patients will need an appointment to see a doctor for diagnosis and treatment, and – thanks to a working relationship with their docs – the case managers can make that happen.
In other words, the case managers will be the linchpin to assuming ACO success. Where the rubber hits the road. Where the light shines. Where the action is. Where the return on investment will be achieved.
Jaan Sidorov, MD, is a thought leader, ‘ blogvocateur’ and the author of over 35 peer-reviewed publications and presenter at 60 health conferences, Dr. Sidorov is a seasoned primary care physician with a working familiarity with health insurance, corporate governance, health service research, disease management and health care quality. Dr. Sidorov also publishes ‘The Disease Management Care Blog which is the original source of this blog post.
Nice post! The PCP/case manager partnership is one that has worked successfully for many in this area.
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