AHIP Institute: 8 lessons from health plans that manage complex patients

team of doctors and nurses talking

Health plans that have member populations with complex care needs face challenges that require these organizations’ leaders to think differently, experts said during a panel at the 2016 AHIP Institute.

headshot of Dr. JainIn his experience working with complex patients, CareMore President and CEO Sachin H. Jain, M.D., (right) said he has learned that sometimes assumptions about a population aren’t correct.

For example, when working with homeless individuals, he found that he “had absolutely no idea what their lives were like.” Contrary to what some would think, foot care--not mental health--was the primary concern among these patients, he added.

Lisa Price-Stevens, M.D., Fallon Health’s vice president of medical affairs, also had a humbling experience to share. Her organization learned the hard way that it was a “big mistake” to use the same program for older-than-65 dual-eligibles to a younger-than-65 dual-eligible population, because their needs are so different, she said.

Both health plan executives have learned a great deal in their effort to design better care for complex patients, and said their experiences have produced the following lessons:

  1. Despite the industry’s increased focus on consumer-driven healthcare, complex patients are not consumers in a traditional sense, Jain said, adding that when someone is diagnosed with a chronic illness, they simply want to be cared for.
  2. Yet health plans must also respect patients’ dignity--including their right to make choices about their care--Price-Stevens said.
  3. Trust is vital in the effort to engage providers, according to Price-Stevens, who noted: “If your provider’s not on board, your care model will not work.” One way to obtain physician buy-in, she said, is to place navigators in care facilities to act as guides for complex patients.
  4. While Jain believes that the foundation of great patient care is great clinicians, complex patients don’t just need one good doctor--they need care teams that work collaboratively. To further this goal, CareMore created a program to teach cross-disciplinary teamwork, he said.
  5. Burnout is a major issue for clinicians who treat complex patients, Price-Stevens said, which Fallon Health address by rotating assignments. Indeed, health plans must also support clinicians who operate at the top of their license and their compassion, Jain said.
  6. Price-Stevens stressed that successful care models require not only transparency and data sharing with all key stakeholders, but a commitment to measuring quality, access and the model’s financial health.
  7. Technology only goes so far, though, as Jain noted that predictive analytics is a “2 percent solution, not a 98 percent solution.” More importantly, systems of care must have the capacity to manage complex patients, he said.
  8. Social determinants of health matter, Price-Stevens added, noting organizations can make more of a difference by paying attention to social factors--such as through partnerships with housing agencies and transportation authorities--than when focusing on obvious medical needs.

All of these lessons require not only collaborative efforts between healthcare organizations but also an unwavering commitment, according to Jain. “As an industry, we need more courage,” he said. “To put into practice what we know works.”

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