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Why Care Management for the Top 5% is Still Negative ROI

January 28, 2017 at 5:32 PM

The top 5% of patients consume over 50% of total health spending. This is no big surprise to those who are in charge of population health managers across the US. Given that historically care management has been a very manual (and expensive) operation, it makes sense why health systems believe just targeting the top 5% is the biggest bang for your buck. However, it is imperative to remember that the key is to realizing positive ROI is bending the cost curve in a value-based healthcare system.

There will always be a significant amount of the patients in the top 5% that will not change total healthcare spend, even with the highest quality care management team. The reality is that an Advisory Board analysis found that nearly one fifth of all rising-risk patients (next 20% of panel) escalate to becoming high-risk every year. Stemming this flow of patients into the high-risk category is the key to finally making a dent in the cost curve.

The question then becomes, how do you quintuple the amount of patients under care management without quintupling the cost of your care management team? The first step is to equip care managers with technology that allows them to have a much wider reach. This has been discussed in a previous blog which can be found here.

While nurse care managers are usually the best employees for monitoring the top 5%, once a group expands to monitoring the top 25% (high- and rising-risk), there becomes an opportunity to hire care coordinators under the nurses to further increases efficiency. Based on our experience working with a variety of world-class care management teams, the best organizations have employed a model that allows their employees to operate at the top of their respective licenses. This not only helps achieve higher financial ROI, but also substantially helps recruiting and retention of the best care management talent. The following highlights how each member of the care management team works together in harmony to improve outcomes for the most challenging patients.

Top of License Care Coordination Model

1. Care Coordinator

The typical care coordinator may have previous experience working in a doctor’s office. They may or may not be a Certified Medical Assistant or Licensed Social Worker. The day-to-day for a care coordinator should be data flows from their remote patient monitoring tool, order prescriptions for patients, ensuring proper documentation, and helping coordinate patient’s medical appointments.

When there is an acute event or concerning symptomatology collected (automatically or telephonic), the care coordinator alerts the nurse care manager.

2. Nurse Care Manager

Nurse Care Managers are the heroes of the care management team. They end up carrying out everything. With either a home visit or a telephonic intervention, vital signs are collected and a patient assessment is completed. The nurse care manager generally provides education to the patient and provides medical intervention up to their top of their license.

When the assessment determines there has been a substantial change or further decompensation of the patient’s current status, the nurse care manager brings a consolidated report to the physician.

3. Physician

The physician’s time should be protected at all costs. It is already universally accepted that physicians are burning out and overworked from having to see increased number of patients every day and take charts home every night to have appropriate documentation.

The physician’s role is to adjust the care plan based on the new findings found by the nurse care manager. When the model is working at its best, for every single patient the doctor needs to adjust care, hundreds of patients had been touched by the care management team and their technology.