CMS recently announced it would begin next January to pay physicians for care coordination activities. It’s about time. As physicians have been saying for some time, any payment system that hopes to encourage value (better patient outcomes) has to start by paying physicians to coordinate the care of their patients. When physicians follow up on referrals or communicate with patients outside of the office, healthoutcomes improve, costs shrink and the patient experience is elevated.
But when care coordination comes at the expense of billable services, as it does now, participation is predictably low. So CMS’s move to finally pay providers for care coordination is a welcome step in the right direction.
Unfortunately, the amount CMS has announced it will pay — just under $42 per month to manage Medicare members with two or more chronic conditions — won’t come close to covering the cost of hiring enough care coordinators for all the patients who need oversight.
The job isn’t an easy one. According to the Agency for Healthcare Research & Quality (AHRQ), the components of effective care coordination include:
- assessment of a patient’s care coordination needs
- information exchange across care interfaces
- interventions that support care coordination
- monitoring and adjustment of care
- evaluation of outcomes, including identification of care coordination issues
Within those parameters are a number of critical tasks. For example, in order for a care coordination program to be effective, the practice must build patient registries and risk-stratify the patients within those registries. Even this seemingly simple task becomes complicated because patients often belong to more than one registry due to co-morbidities. In the U.S., 1 in 4 adults has two or more chronic conditions, and these numbers increase as patients age.
Once the registries are built, the EHRs for those patients need to be reviewed regularly to identify care gaps, such as being overdue for a physician visit, preventive screening (such as mammograms for women over 40) or lab work (such as HbA1c tests at particular intervals for diabetics). Identifying care gaps should not be limited to the patients in front of the physician, i.e., those who are coming in the next day or the next week; they should occur across the entire patient panel if they are to be effective in improving the health of populations. In addition, these gaps must be communicated to the patients as well as to their physicians or nurses, which requires even more time and labor.
Once appointments are scheduled, patients should receive reminders to increase the likelihood they will keep the appointment. For patients with chronic conditions, time should be set aside to educate them about their condition(s) and show them how becoming engaged in their own care will help them improve their quality of life.
Clearly, doing care coordination correctly requires a great deal of work. So far, insurance companies have been willing to foot the bill for pilot programs, but as care coordination expands across entire patient panels or populations it is unlikely those contributions will be enough to hire the number of care coordinators required to operate this way.
One way to meet this challenge is to use information technology wherever possible to automate care coordination and care management activities. Technologies such as registry building tools, care management software and automated outreach tools have all been deployed successfully, in conjunction with EHRs, to manage patient populations. They allow practices to scale up care coordination significantly while only adding a handful (or fewer) of care coordinators to the staff. Done correctly, an automated care coordination strategy can pay for itself, allowing commercial insurance or CMS payments to drop to the bottom line.
The automated stratification of patients into health risk categories is especially important to groups seeking to include care coordination as part of a population health management (PHM) program. Technology can be used to automate the building of patient registries, and then review electronic health records within those registries to identify those at the highest risk of an event. As well as those who are trending that way. Evidence-based clinical protocols, which can be customized by physician practices, then trigger alerts in the registries.
When these registries are linked to an outbound messaging system, patients are notified by automated telephone, email or text messages to contact their physician for an appointment, lab work or other intervention. No human action is required throughout this process, minimizing staffing requirements.
Some registries can even send actionable data to care teams prior to patient visits. This activity allows care coordinators to plan their time more effectively, giving them the opportunity to spend more time with patients who need additional help. For example, if an out-of-control diabetic is identified by the registry, the care coordinator can plan to spend a half hour with the patient after an appointment explaining the importance of proper diet and exercise and creating a plan the patient can follow based on the best practices.
Using automation in this way allows technology to do what it does best — quickly cull through mountains of data to look for the exceptions that require attention — while allowing care coordinators to focus their efforts on working with patients to provide timely interventions and improve outcomes.
One other advantage of using technology to identify care gaps is it can help ease the transition from fee-for-service to value-based billing. Identifying patients who are overdue for physical examinations or preventive screenings can create an additional, untapped revenue stream while improving patient health, helping practices avoid preventable hospital admissions.
This isn’t just theory. You can find measureable results from care coordination pilot programs all over the Internet. That CMS is finally taking an important first step towards universal care coordination is a good thing. But let’s not kid ourselves. There will not be a bottomless pit of money. So physician practices would be well advised to take advantage of advances in PHM technology. There’s no other way to rapidly and extensively scale up their care coordination capabilities without substantially adding to their staff.
Richard Hodach is chief medical officer, Phytel and the author of Provider-Led Population Health Management.