Care Management 2020

Care Management is the simple idea of assisting individuals and their support system to become engaged in a process designed to manage health conditions more effectively.  In an ideal environment, care managers (most often specialty trained nurses), are experts in working with individuals to identify their goals and locate the specific support services that enhance the patient’s well-being. When faced with the array of choices and challenging decisions, care managers provide support to find the best solutions for individuals and their families.

Having been in the industry for nearly 30 years, I’ve both watched and helped lead change in this space. The healthcare community has moved from a very basic form of care management known as utilization management to today’s member portals and self-help tools. But health systems are finding they need something more significant.  Hospitals and health systems have trained staff to facilitate a discharge, to navigate a patient quickly through choices for cancer or cardiac treatment or even outreach programs to attempt to avoid readmissions – yet most of these efforts are isolated within a single specialty or function and rarely look holistically at the patient and all their clinical and care issues. 

For example: Cancer patients are rarely perfect specimens of health other than their cancer diagnosis. They likely have diabetes, or hypertension. Perhaps they have a challenging living environment at home, or they may live in a rural area outside the city with limited access to medical services. Or perhaps this is a recurrent issue and their overall health status is already compromised. Now consider the fact that nearly 50% do not have a primary care physician – the need for new care management models is obvious.

As we enter an era of bundled payment models and shared risk – having expertise in care management that merges the acute clinical situation with the underlying medical issues of the patient and their own symptoms, living environment, access points, knowledge and state of health is essential to improve outcomes and reduce costs.

The bottom line:  The underlying business model of most of today’s care management processes is dated.  It was built for a different era and for a different purpose.  It’s time for a change.

 Highlights of Legacy Care Management

Before the Affordable Care Act took the industry by storm in 2010, health plans were the primary group who cared about managing the health of populations. These payers cared a lot, because they had so much economically on the line. They needed data-driven systems that could help identify and manage patients who might incur large healthcare expenses at some future time. The care management industry was born out of this need. 

What began as a simple notion in the early 1980s, has had layers upon layers added over the years with very little change in the underlying business model. These legacy care management systems look much like a ball of duct tape - utilization management, case management, disease management, wellness and prevention, financial incentives for providers and individuals to change behavior, predictive tools, provider portals, nurse navigators, member portals – all with good intention - but as relevant today as a VHS tape in a streaming media world. 

These old style care management systems have certainly evolved over time, and they typically worked like this:

  • Utilizing the data sources available, health plans would analyze their claims data for the people whose health they insured – looking for the outliers of cost and use.
  • Insurers would notify employers if they had a lot of high-risk people within their covered work force. They would do the same evaluation for their own insured members.
  • Employers would deploy a variety of incentive programs to try to reduce the future cost of care for those patients. Company weight-loss contests, walk-a-thons and health club membership subsidies were typical examples of such wellness programs.
  • The payer’s care management systems would further target at-risk individuals by sending letters and faxes to doctors’ offices suggesting they look into the possible gaps in care and offering to link individuals to community resources. Often even “rating” the doctor on how well they followed their “to do” list.
  • Over the past 20 years, health plans have built massive infrastructures of phone-based nurses who would call doctors and patients to alert them to potential issues and follow up to make sure the issue was being addressed – trying desperately to be the “glue” between the bricks that represent every type of provider.
  • As payments models changed, hospitals needed care planners to facilitate the patient’s discharge home in order to profitably perform in a DRG world. This function forced interaction with SNFs, home health providers and equipment companies.  Yet, they had no shared incentive for success.
  • Hospitals added added “navigators” (primarily serving a scheduling and appointment follow-up function) to help keep the patient in their own system and reduce the confusion for the patient on what’s next. These have worked relatively well within single specialties but fail the patient when the patient has co-morbid conditions.
  • Physicians are trying to add care support to their practices to manage patients in between office visits – and primarily doing so by hiring someone to make outbound calls to patients with check-ups and reminders. They have no real tools to use to prompt these interactions, to record these interactions, nor to determine which patients most need the extra support.

Within this giant ball of duct tape, each of the players – the health plan, the hospital system and the practitioner - have slowly figured out that they actually need the patients’ participation and deep engagement in order to make all this care management work. So patient engagement capabilities like online health records and employee wellness portals were added to the mix.  But the patient was simply a by-product of a legacy system originally designed to keep providers “in line.” 

It’s Time for a New Business Model

The entire care management market is under serious strain – the underlying business model is mostly broken, costly to operate, employee heavy, and not scalable. The basis of analysis - healthcare data (claims) - is typically retrospective in nature, often delayed by one to three months.  Without timely, relevant data, one cannot address today’s reality of needing to know, accounting for and supporting the day-to-day needs of individuals with significant medical conditions.   

Care management data do not universally include the real time information required for critical insight.  Even more important, there is virtually no patient reported data collected by anyone. At best, today’s data models are derived from claims, making a series of assumptions about the current patient status that are largely wrong.  Without day-to-day patient reported information (especially for those who have significant illness), nothing changes. 

The big gains from this entire care management approach have plateaued.  Most of these programs are bloated with layers of beaucracy and largely out of touch with the individual consumer.

So what should take its place now? There are lots of buzz terms floating out there: Accountable Care, Population Health Management, Value-Based Care, Patient-Centered Medical Home. But in order to be different, it all comes down to this simple notion –the new business model of care management must involve a massive shift from silos of care management to strategic partnerships that include the patient, the provider(s), payers and technology-enabled strategic care partners.

To move away from the “we know best” model to a consumer-centric model requires transformational thinking of care management systems. For starters, we must focus on these 4 key areas:

  1. Developing tools and indicators that immediately identify new acute diagnoses that must be managed.  Each day, our health plans enroll members in their plans who no longer have waiting periods as mandated by the Affordable Care Act (ACA). It’s vital to know which of these new members will become high-cost members as soon as possible.
  2. Community-based care support must be implemented. A support model that links the health plan, various care partners and providers in the field must become ubiquitous.  These teams need remote access to share insights from their interactions with patients.
  3. We should engage the consumer as an active participant in their care management through their smartphone. The patient and their family want be able to have 24/7 access to clinical support (especially those with serious or life-limiting conditions). The era of an evening “call service” or “go to the ER” must end.
  4. Today’s care management partnerships must share and act upon relevant data so that the time gap between practitioner office visits and treatment cycles are coordinated and the patient feels engaged, supported, well informed, and actually “cared for”.  We should link this work to retail health and employers’ on-site health clinics to coordinate care management as part of employer-based care management programs.  We should embrace remote, electronic monitoring of members’ biometrics such as weight and blood pressure.


Let’s face it; payers and providers have tended to butt heads since the first attempts were made to manage care by payers. But in the world of patient-centered care, these groups need each other more than ever.

With over 90 percent of the actual healthcare spend in the U.S. still based on the old fee-for-service model, the natural conflict between insurance companies and providers will linger for a while. The speed of technology innovation will always outpace the ability of any one payer or provider to truly deliver all the solutions a newly at-risk population healthcare model will require.

In all this, we must deliver on the promise of the Triple Aim framework developed by the Institute for Healthcare Improvement, which both optimizes the patient outcome while it optimizes the health system’s performance. These new care management models must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the patient’s quality of life and the health of populations; and
  • Reducing the per capita cost of health care.

One of the key objectives of care management, controlling the rise of medical costs, remains unsatisfied. And while the quality of care focus is having an impact, the United States continues to have one of the unhealthiest, costliest populations in the world. We focus more on the over-treatment than really understanding the patient’s goals and supporting them to have the highest quality of life possible. Furthermore, the experience of health care for many people is largely chaotic and unsatisfying.

It’s time to use our entrepreneurial and innovative thinking to bring a new care management business model to the market. Let’s work together to create a business model that is about people; individuals and their families with unique medical, emotional, spiritual, cultural, literacy, economic and social needs (the key determinants of health).  It’s time for a business model in care management that actually is focused on the word “care” rather than “management”.   That's what we're doing at Narus Health. After all, for those of us committed to this space, it’s all about Human Care.