The Pacific Business Group on Health and the Health Care Transformation Task Force have released a report and contracting tool to assist providers and payers with the care management of high-need, high-cost patients.
PBGH, a non-profit coalition of large healthcare purchasers, and HCTTF, an association of health care payers, providers, purchasers and patient organizations, interviewed 11 organizations that have operated care management programs for these patients for two years or more to form the tool.
HNHC patients, a small number of individuals with complex medical, social and behavioral needs, make up 5% of the U.S. population but account for roughly 50% of the country’s annual healthcare spending.
These patients, many of whom live with three or more chronic conditions, use the largest proportion of healthcare resources in the U.S. Improving their care has long been a priority for the industry.
David Blumenthal, president of the Commonwealth Fund (a nonprofit that supported the initiative), proposed in a New England Journal of Medicine article that, to meet the needs of these patients,
healthcare organizations must first understand the population, then identify evidence-based programs that offer them high quality care at a low cost, and finally accelerate national adoption of such programs.
This joint effort fits into that last initiative.
The resources, which include a whitepaper and a set of guidelines, provide insights in care contracting including HNHC-targeted contracting, whole population contracting or a combination of the two.
“High-need high-cost contracting is where you have these more advanced provider systems that are contracting primarily or exclusively for medically-complex patients,” Caitlin Sweany-Mendez, director of transformation facilitation and support at the task force, explained. “It tends to be a bit more sophisticated and flexible” with how people are identified and targeted as compared to whole population contracting.
Key suggestions in HNHC-targeted contracting for delivery system executives include factoring in the importance of service area demographic variations in program design, ensuring that contracts last at least three years to allow the organization to develop and being thoroughly ready before moving toward advanced risk or fully capitated contracts.
In whole-population contracting, the report stresses that delivery system executives should invest internal resources in care management, foster open, cross-departmental communication and enhance the connection between leadership and front-line care delivery providers.
“Decisionmakers,” the report reads, “must understand the clinical and social nuances of the populations that their organization serves” — something that’s been overlooked in the past with complex-need patients.
The resources also include guidelines for contracting and clinical program management.
What’s key, according to the report, is to identify people with high-risk profiles and high costs through risk stratification, but also to focus on segmenting HNHC patients based on their specific constellation of needs. This “tailored care management” improves health and financial outcomes, according to Jeff Micklos, the executive director of the task force.
Also key is providing access to health information technology and data to coordinate patient care.
Although the report found guaranteed access to data is a good tactic in identifying HNHC populations and properly managing their needs (along with real-time data updates, enrollment data sharing and supplemental health information), data sharing is currently underused by care managers.
“You think [data access] would be absolutely critical,” Micklos said, “but we were surprised at how many providers didn’t have formal data agreements with their payer partners. It seems to us that’s a threshold element of any contract."
He continued: “That’s an opportunity for programs who are starting out — to realize that’s got to be one of the first, key elements of any contract.”
A barrier to widespread adoption of HNHC programs is return on investment and worry around receiving adequate payment for service, although the move to value-based payment by payers increases provider accountability in quality of care and cost containment.
For an HNHC care management program to be sustainable, the report found, it should provide an ROI over the course of multiple years and meet specified contractual targets.
“It’s about making sure that you at least have rates that are paid to you that cover the range of services that you’ve providing,” Micklos explained, stressing that the programs can pay for themselves over time.