Implementing Successful Care Management Programs for High-Cost Patients

Gordon Swanson/shutterstock.com

As healthcare delivery increasingly moves from volume-based care to value-based care, providers are needing to adopt new practices to meet what is now commonly referred to as the triple aim of healthcare delivery—improving the patient experience of care (which includes satisfaction and quality), improving the health of populations and reducing cost.¹

Among the most difficult population of patients for which to achieve this triple aim is the group of patients with chronic, often multiple, conditions that incur a high burden and cost for both patients and the healthcare system. Among these patients are those with musculoskeletal conditions, as highlighted in a 2013 study, which found that musculoskeletal disorders were among the diseases associated with the highest levels of disability and burden of disease in the U.S.² Thus, rheumatologists are among the providers who are particularly in need of finding ways to improve outcomes for their patients.

Accountable Care Organizations & More

Specific ways of better treating this population of patients are now being tested in a number of private and public program initiatives. Some familiar types of programs include accountable care organizations (ACOs), patient-centered medical homes, readmission initiatives and care transition programs.

Data on these programs are now becoming available, with several recent reports shedding a light on what has worked well and what remains challenging.^3-5 What emerges is a sense that what works at the micro-level works at the macro-level—that is, just as the best treatment for each patient is tailored to that patient’s individual needs, the best program appears to be the one that meets the particular needs of the population.

Douglas McCarthy, PhD, senior research director, The Commonwealth Fund, New York, a co-author of a 2015 report on outcomes data from a number of successful programs, emphasized that one type of program does not fit all circumstances.³ “New care models have a better chance for success if they are designed and adapted to meet the needs of particular population segments, payment arrangements and organizational settings,” he says.

In another report on successful programs published in 2015, Gerard F. Anderson, PhD, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, also highlighted the need to tailor programs to meet the needs of its population.⁴

“One of the key attributes [of successful programs] is the ability of the program to adapt to local situations,” he says. Providers are more apt to develop and implement successful programs than insurance companies because they know what their patients need and their circumstances require.

Key Features of a Successful Program

Both reports by Dr. McCarthy and Dr. Anderson highlight key features common to the programs they assessed that succeeded in improving patient outcomes and/or reducing cost (see Table 1, right).^3,4