Care management programs are a key step payers can take to help improve their customer service and member outreach while also reducing their costs. These programs, which often address certain patient populations with particular conditions like diabetes, obesity or heart disease, help payers identify patterns that could be early indicators of failing health.
Essentially, establishing care management programs gives payers the opportunity to improve care outcomes and reduce future costs, according to Judith Frampton (pictured), former vice president of medical management at Harvard Pilgrim Health Care.
"When members are informed and engaged in their health management regimens, they have a better quality of life both physically and emotionally, and all stakeholders win," Frampton, who now is principal at independent consulting company Judith Frampton LLC, told FierceHealthPayer. We talked to Frampton to learn more about how payers can benefit from care management programs.
FierceHealthPayer: Why should insurers create care management programs or augment their current processes?
Judith Frampton: By implementing robust and integrated care management programs, insurers are much better able to relate to their members as the dynamic, ever-changing people they are. By adding biometric tools and clinical risk predictors to the more standard claims-only view, payers get a complete picture of their members without being reliant on static data. It's even possible for plans to use more sophisticated tools that account for the personalities of their members. For example, a care manager can approach a proactive member in a completely different way than he or she would a member who is more inclined to shy away from thinking about health decisions.
FHP: What are the benefits payers will reap once these programs are in place?
JF: The great news about the benefits of an effective care management program is that they compound and accrue with time. Payers see administrative cost savings, medical cost reductions, improved clinical outcomes, as well as more effective data analytics. Payers will also see customer satisfaction rates rise across members and accounts, and customer satisfaction is king. When members feel that they are listened to and that approaches are personalized, they are more inclined to be active participants in their healthcare experience. Motivated and engaged members can mean significant costs savings for plans.
FHP: How should payers determine the best system to fit their current IT infrastructure?
JF: Payers should never expect to flip a switch and instantaneously have an effective care management system. It is like any major decision and purchase--the organization should figure out what the priorities are, what the budget is and get as close to what it wants within its means. Payers should certainly evaluate things such as the ease of operation for the end-user, the ease of integration with existing systems and data sources, forward compatibility with future needs, and how well the capabilities of the system fit the purpose and goals of their care management program. They should ensure that the system they choose has excellent reporting capabilities and is flexible, secure and compliant.
FHP: What are the most common pitfalls insurers run into when setting up care management systems?
JF: Not ensuring that there is a tight and collaborative alignment between the technical and clinical folks. These groups are very well-intentioned subject-matter experts, but they tend not to "speak the same language," which can create unintended disconnects along the way.
Another trap to avoid is not leaving enough lead time and not adequately appreciating just how much preparation is needed on the part of the payer. These organizations need to be sure that the right people with the right skill sets are working on each aspect of the project to ensure a smooth implementation.
Lastly, they have to be able to sort out the "must haves" from the "nice to haves." What must they have to realize their care management goals? If they choose a flexible, extensible system, the "nice to haves" might fill in later as the goals evolve. Care management has now become a strategic priority for most healthcare organizations. Therefore, executive sponsorship and involvement are critical to successful implementations.
FHP: Can you provide lessons learned from the care management programs you've implemented?
JF: One thing we have learned is that care management programs can empower payers to identify patterns of care that might mean something is failing in the outpatient management of members' conditions. With the right software, organizations can detect patterns that may be early indicators of worrisome trends. For instance, a member may have had five doctor visits in the previous two months and answered questions on a health assessment demonstrating some concerns. While this pattern may not represent significant current costs to a plan, it could mean this member doesn't adequately understand how to manage his or her health situation, and represent an early opportunity for reducing future costs and improving outcomes.
Care management programs offer multiple opportunities to clear up misunderstandings that may occur due to lack of time in the regular physician office visit setting. When members are informed and engaged in their health management regimens, they have a better quality of life both physically and emotionally, and all stakeholders win.