Employer Healthcare Solutions

Revolutionizing Population Health Risk Reduction: A Shift from Historical Costs to Root Causes

Clinical Consulting, Employer Healthcare Solutions /

Written by Scott Conard, MD When it comes to population health risk reduction, the conversation is evolving. Historically, in the U.S., managing health costs has often been approached from an actuarial perspective—calculating insurance premiums based on past expenses and statistical projections. While this method has served its purpose, it focuses on trailing indicators like price per procedure and frequency of use, leaving the underlying drivers of healthcare costs largely unaddressed. But now, a shift is happening. We’re moving beyond simply accounting for costs to asking critical questions: What’s causing these costs to rise? What are the leading indicators that drive health risks and, ultimately, healthcare utilization? Moving Beyond Actuarial Science Traditional actuarial science calculates costs by factoring in variables like age, geographic location, medical diagnoses, and prescription usage. Insurers then project future costs based on past patterns, layering in adjustments for population demographics. While precise in its methodology, this approach is inherently backward-looking, focusing on how much was spent last year rather than proactively addressing what might reduce future spending. At its core, healthcare costs boil down to two key factors: price and use. But focusing solely on these metrics ignores a fundamental truth: the largest driver of healthcare cost is the risk of illness within a population. A high-risk population will inevitably lead to higher utilization and costs, while a low-risk population is significantly less expensive over time. As discussed HERE, we discuss how the real enemy in healthcare is disease, not just fighting costs Identifying and Addressing Health Risks To reduce health risks, we must first identify them. The answer lies in analyzing the population’s disease burden and the lifestyle factors driving it. Experience has shown that approximately 30% of a company’s population will eventually account for the majority of high-cost claims. More importantly, about 70% of those costly claims stem from conditions that could have been mitigated through early intervention and risk reduction. Lifestyle and Emotional Health: The First Line of DefenseMany of the conditions driving healthcare costs are preventable. Addressing lifestyle factors and emotional well-being plays a pivotal role in risk reduction. Strategies include: Navigating Healthcare Smarter The second pillar of health risk reduction involves empowering individuals to make smarter healthcare choices. This includes: High-Quality Care = Lower Costs A critical insight emerges when we focus on proactive health management: the highest-quality care is often the least expensive care. By identifying and addressing risks early, we not only improve health outcomes but also manage costs more effectively. Predictive analytics allow us to foresee who may require expensive treatments like surgery or dialysis, enabling timely interventions that are both effective and cost-efficient. The Future of Population Health This shift in focus—from trailing indicators like price and use to leading indicators like disease risk—represents a fundamental transformation in how we approach population health. By addressing the root causes of illness, promoting healthier lifestyles, and ensuring access to high-quality care, we can achieve significant reductions in healthcare costs while enhancing overall well-being. The path forward is clear: organizations must prioritize proactive health management strategies that address the underlying drivers of risk. By doing so, they can create healthier populations, reduce costs, and foster a more sustainable healthcare system. This isn’t just good for business—it’s essential for the future of healthcare. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

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Exposing Hidden Waste: Out-of-Network Payment Schemes

Employer Healthcare Solutions /

As a senior executive, you’re constantly focused on efficiency, transparency, and maximizing the value of your company’s investments. Healthcare benefits—often one of your organization’s largest expenditures—should be no exception. Yet, many employers unknowingly bleed money due to hidden fees and opaque out-of-network payment arrangements. If you think a polished benefits package guarantees fairness and cost control, think again. Pulling Back the Curtain on Out-of-Network “Savings” ProgramsConsider a scenario: You have 5,000 employees. Your broker partners with a major carrier that promises a cutting-edge out-of-network cost-management program. On the surface, you’re shown impressive statistics: “We saved you X%!” “Your plan saved hundreds of thousands of dollars!” But ask a crucial question: Saved compared to what? Suddenly, the narrative isn’t so clear. One leading carrier’s program, One of the major insurance carriers offers out-of-network “payment integrity” solutions. The carrier presents data showing significant reductions in billed charges—numbers that look like heroic cost containment. Yet, behind these reported “savings,” the carrier often takes a percentage cut for themselves, effectively turning your plan’s supposed cost control measure into a revenue generator for the insurer. Real-World Example: The 13-Hour Office VisitImagine a provider billing over 50 increments of a single 15-minute service in one day—implying a marathon 13.5-hour visit. Under standard Medicare rates, this service might only be worth about $32 each time. Yet the provider’s billed amount was thousands of dollars, with the plan paying only a fraction. On paper, this program would claim massive “savings.” But in reality, the carrier charged the plan a hefty percentage of that “avoided” cost—far exceeding what the doctor actually received. In one particularly egregious case, the provider was paid a mere $61 while the insurer pocketed $3,700 in “fees.” The question executives must ask is: If the insurer knows these questionable billing practices are happening, why don’t they stop it? Quite simply, they profit from the difference. Where the Waste Happens—and How to Fix ItThis kind of wasteful spending arises when employers accept opaque arrangements without fully understanding the underlying payment mechanics. To address this problem, organizations must: 1.     Renegotiate During RFPs:Start strong by establishing clear contract terms that prohibit the carrier from earning more than what is paid to the provider. Demand transparency and define “savings” in measurable, meaningful terms. 2.     Limit Out-of-Network Services:Consider eliminating or tightly restricting out-of-network benefits. Handle exceptions individually to ensure members get needed care without giving carriers an open invitation to pad their margins. 3.     Engage Expert Negotiators:Partner with advisors who understand these complex billing games. They’ll ensure plan language and fee structures minimize the potential for misaligned incentives. Implementing these strategic approaches can reduce your per-employee per-month (PEPM) costs significantly. In fact, by addressing just one out-of-network program, some employers have seen immediate reductions of up to 7.5% of total healthcare spending. Data-Driven ResultsEmployers who actively root out these hidden fees and adopt transparent payment models have achieved substantial cost reductions. Data shows that organizations employing robust payment integrity strategies and strict out-of-network controls can drive down total health plan costs by as much as 15%. Your Next Move: Take Back ControlAs an executive, every dollar counts. In a landscape where healthcare spending spirals ever upward, protecting your plan from hidden charges and self-serving “savings” schemes is critical. Don’t leave your organization’s financial health to chance. Take the first step toward total transparency and meaningful savings. Contact us to learn more and schedule a consultation. Our team will review your existing arrangements, identify hidden waste, and help you negotiate a plan structure that truly prioritizes cost control. Stop letting opaque deals drain your resources—act now and put your company on the path to zero trend. Written by Rob Thwaites

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The Real Enemy in Healthcare Benefits: Fighting Disease, Not Just Managing Costs

Clinical Consulting, Employer Healthcare Solutions /

By Mike Adams and Scott Conard MD When it comes to healthcare benefits planning, companies often get sidetracked, thinking that the main challenge is controlling costs. But here’s the real truth: the true enemy isn’t high premiums or rising deductibles; it’s the disease itself. Disease is what drives up healthcare costs, disrupts productivity, and takes a toll on both employees and employers. By refocusing our efforts on fighting disease and supporting long-term wellness, we can create a sustainable, effective healthcare benefits strategy that benefits everyone. Empowering Employees to Fight Disease: A Partnership Approach In the fight against disease, employees and employers need to align their efforts. Employers play a crucial role in providing the resources, financial assistance, and tools employees need to manage their health effectively. But it’s not just about giving access to healthcare services; it’s about fostering a proactive health mindset. Employees need to take ownership of their health. This partnership means that while companies provide the tools, employees must also put in the effort to use them effectively. Moving from Transactional to Relational Healthcare One of the biggest obstacles to creating a sustainable healthcare strategy is that too many people still view healthcare as purely transactional. In the traditional model, employees go to the doctor when they’re sick, get a prescription, and call it a day. However, this approach doesn’t solve the root problem; it merely addresses symptoms as they arise. The solution is a shift from transactional to relational healthcare. Just as financial advisors moved from selling stocks and bonds to holistic wealth management, healthcare providers are starting to focus on population health management. This approach prioritizes long-term health and wellness over short-term treatment and one-off doctor visits. Population health management looks at the bigger picture—helping individuals stay healthy and preventing disease from occurring in the first place. The Problem with Cost-Centered Benefits Planning Many companies have relied on brokers, insurance providers, and pharmacy benefit managers (PBMs) to reduce costs. However, focusing only on cutting costs without addressing the underlying issues—namely, disease and lack of preventive care—leads to a broken system. Often, these brokers and PBMs are incentivized by rebates, prescription volume, and other revenue-driven structures. This creates a conflict of interest, where decisions may prioritize profit over the well-being of employees. Year after year, this results in a steady increase in healthcare costs, with the average annual rise in premiums hovering around 5% to 10%. To break this cycle, companies must shift their focus from short-term savings to addressing the real issue: preventing and managing disease. Only by aligning incentives toward long-term health outcomes can companies sustainably control healthcare costs. Disease is the Enemy: The Path to Sustainable Healthcare Benefits The true solution lies in approaching disease as the primary challenge. When employers focus on health improvement instead of just managing expenses, they can create a benefits plan that is both cost-effective and impactful. This involves: When employers and employees work together, supported by a healthcare benefits plan that prioritizes fighting disease, the benefits extend beyond the bottom line. Healthier employees lead to a more productive, engaged workforce, reduced absenteeism, and ultimately, lower healthcare costs. Building a Healthier Future: Fighting Disease Together By recognizing disease as the real enemy, companies can begin to reshape their healthcare benefits strategy in a way that truly serves employees’ needs. Empowering employees to take charge of their health, focusing on preventive care, and partnering with providers who share a commitment to wellness can transform healthcare from a transactional system to a relational, proactive one. Disease is the real enemy in healthcare benefits planning, and by uniting against it, we can create a system that doesn’t just manage costs—it improves lives. Let’s move past broken incentives and focus on what truly matters: building a healthier, more resilient workforce.

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Health Risk Engagement Strategies: Driving Change Before It’s Too Late

Clinical Consulting, Employer Healthcare Solutions /

For executives managing health plans, one of the biggest challenges is engaging individuals who are in the early stages of disease risk progression but feel perfectly fine. These individuals, often unaware of the looming consequences, present a significant opportunity—and a unique challenge—to healthcare strategies. Once someone becomes symptomatic, behavior change is much easier; they’re desperate to feel better. However, by then, it’s often too late to reverse the damage. Instead of cheaply and effectively addressing the issue, we’re left managing a chronic condition for the foreseeable future. The key question: How do we engage people early, before symptoms appear, and inspire them to take meaningful action? This is where cutting-edge health risk engagement strategies, driven by predictive data and real-time activation technology, become a game-changer. Our algorithms utilized by the MyPHA team is your solution to this problem.  Shifting the Paradigm: From Retrospective Cost Analysis to Proactive Risk Engagement The status quo in healthcare analytics relies on retrospective cost-based reporting. Most organizations are equipped with tools that answer questions like: These data points are useful for understanding the past but do little to impact the future. They focus on individuals who are already in the high-cost, high-risk category—individuals whose health trajectory has already caused irreparable harm. What’s missing from this equation is predictive engagement—the ability to identify the individuals who are trending toward risk before they become symptomatic and to intervene effectively in real time. Consider this: 70% of today’s high-cost individuals won’t be the same people next year. If you’re only looking at historical data, you’re blind to the emerging risks within your population.  Why Predictive Engagement Matters Let’s look at the CFO perspective:“I’ve already got reports. I know I have 384 diabetics and 264 people with hypertension. I have programs in place for them. Why do I need anything more?” Here’s why: Traditional reports don’t tell you who your next high-cost individuals will be, nor do they provide actionable insights about how to prevent them from becoming costly. They miss the nuances of health risk drivers—factors like comorbidities, social determinants of health, geographic influences, and behavioral patterns—that determine whether an individual can avoid a serious medical event. Predictive engagement goes beyond labels and costs. It examines the whole person—integrating data about: This holistic approach enables organizations to answer the most critical question: How can we prevent costly and emotionally taxing events before they occur?  Engagement, Activation, and Support: The Pillars of Early Intervention Effective early intervention requires a three-pronged approach: For employers, early intervention is not just a health imperative; it’s a financial one. But this requires a shift from reacting to past costs to proactively managing future risks. By investing in predictive analytics and engagement technology, organizations can reduce costs while improving outcomes for individuals.  Conclusion: The Future of Health Risk Management The old approach—focusing on retrospective cost and disease management—is no longer enough. Health risk engagement strategies must evolve to focus on real-time insights, whole-person care, and proactive prevention. The stakes are high, both for individual lives and corporate budgets. But with the right strategies, tools, and commitment, we can make a measurable difference—shifting the focus from managing disease to building health and resilience. As executives, the question isn’t, “Why should I care about your data?” It’s, “How can I afford not to?” By embracing proactive engagement, activation, and support, you can ensure your organization is leading the way in creating healthier, more productive populations. That’s a future worth investing in.

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Realigning Incentives for Better Health Outcomes and Lower Costs

Clinical Consulting, Employer Healthcare Solutions /

For executives responsible for managing their organization’s health plan, there’s a crucial question worth asking: Is our current system really designed to treat each individual and improve their health? On the surface, the answer might appear to be “yes.” After all, the system has data, information, resources, and influence at its disposal. But take a step back and ask yourself: How is it working for you? If the system truly prioritized individual health, the numbers would tell a different story. Healthcare costs in the U.S. would be at least half of what they are today. Instead, costs continue to rise at a staggering rate of 5% to 10% annually, leaving organizations and their employees struggling under the weight of increasing premiums, higher deductibles, and diminished outcomes. The Misaligned Incentives Here’s the hard truth: The current system is not designed to treat the individual effectively. Why? Because misaligned incentives drive it. Many players in the healthcare ecosystem profit more when costs go up. In fact, rising costs are often baked into their business models. This misalignment has created a scenario where nearly one-third of healthcare spending is wasted on fraud, waste, and abuse. These inefficiencies enrich middlemen and other unnecessary stakeholders while leaving employers and employees to foot the bill. Worse yet, 70% of high healthcare costs could have been prevented if root causes were addressed earlier. A Smarter, More Aligned Approach What if we could use the same intelligence—data, information, and systems—but act on it differently? What if we focused on making people healthier and tackling waste at its core? This approach is not only possible but also financially and operationally realistic. By investing in high-quality care that addresses the root causes of health issues, organizations can achieve better outcomes and lower costs. High-quality care is the least expensive care because it prevents the need for costly interventions and reduces the churn of treating symptoms without resolving the underlying problems. A Path to Sustainable Savings Consider this: if we worked to eliminate a portion of fraud, waste, and abuse each year for the next five years while improving the health of employees, could we stabilize our costs? The answer is a resounding “yes.” Here’s what that path looks like: The Payoff By realigning incentives and focusing on root causes, companies can break the cycle of escalating costs. Over time, this shift leads to a healthier workforce, more predictable expenses, and a competitive edge in attracting and retaining talent. As leaders, it’s up to us to ask the tough questions and take bold action. The fly in the sauce isn’t going to fix itself—but we can. Together, we can create a system that works for individuals, organizations, and the bottom line. Are you ready to take the first step toward a healthier future for your team and your company?

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The Critical Role of Health Insurance in Employee Wellbeing

Employer Healthcare Solutions /

Jan 09, 2025 The state of healthcare in America today is far from ideal, with many employees struggling to access affordable, high-quality care. Health insurance plays a crucial role in employee wellbeing, impacting not only their physical health but also their financial stability and overall job satisfaction. Employers who recognize and prioritize the importance of a well-structured health plan can significantly improve employee wellbeing and their company’s bottom line. The Current Healthcare Landscape Many employers are self-insured, meaning they assume the risk of healthcare costs for their employees. This puts them in a position of essentially running a small health insurance company within their business. Unfortunately, many companies lack the expertise needed to manage these plans effectively. This often leads to overspending, wasted resources, and employee dissatisfaction. Additionally, the current system is often plagued with misaligned incentives where brokers and consultants may prioritize their own commissions over the best interests of the employer and employees. Impact on Employee Health and Wellbeing When health insurance plans are not managed effectively, the negative consequences are felt by the employees. High deductibles and out-of-pocket costs can deter employees from seeking necessary care, leading to delays in treatment or avoidance of preventative services. This is particularly true for employees with chronic conditions or those who require regular medication. The stress of financial burden from healthcare costs can lead to decreased productivity, absenteeism, and lower overall job satisfaction. Employees who feel that their health plan is inadequate may also experience lower morale and increased stress levels, which could impact their performance. In contrast, a well-designed health plan can support employees in maintaining their health, offering resources and support for chronic conditions, mental health, and access to quality care. How Employers Can Improve Employee Wellbeing Through Health Insurance Employers play a pivotal role in changing this dynamic and creating a healthcare system that benefits both the company and its employees. Here are a few steps to take: C-Suite Involvement: CEOs and CFOs need to get actively involved in the management of healthcare benefits. They must view it as a crucial part of their business, applying the same financial scrutiny as they would to any other significant expenditure.Transparency and Audits: Employers should demand transparency in all contracts with TPAs, PBMs, and brokers. Regular audits should be conducted to ensure that the plan is operating efficiently and in the best interests of the employees.Focus on Data and Risk Assessment: By understanding the health risks of their employees, employers can create targeted interventions and support programs. This approach enables more personalized and effective healthcare strategies.Value-Based Care: Move away from traditional fee-for-service models to value-based care, which incentivizes providers to focus on health outcomes. This includes partnering with providers who are committed to improving patient health and reducing costs through prevention and early intervention.Employee Education: Employers should prioritize health literacy and provide resources to help employees make informed decisions about their care. This also includes educating employees about their own health risks and encouraging proactive engagement in their care.Humanize the Problem: It is important to listen to employees, understand their challenges with the healthcare system, and use these stories to drive change. Personal experiences can help leadership recognize the real-world impacts of their health plan decisions. Ready to transform your health insurance plan into a powerful tool for employee wellbeing and organizational success? Take the first step toward a smarter, more impactful healthcare strategy today. Empower your team with a plan that reduces costs, enhances productivity, and prioritizes their health. Let’s create a healthier, more engaged workforce together. Contact us now to start building a plan that works for everyone. Written by Rob Thwaites Pathway to Zero Trend Contact us The Critical Role of Health Insurance in Employee Wellbeing

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November 26, 2024: Meet Margaret, a 47-year-old female employee in your company.

Employer Healthcare Solutions /

Meet Margaret, a 47-year-old female employee in your company. How would your company’s benefits support her? Margaret is a 47-year-old hard worker and is a valued member of her work group at your company. She’s been employed by your company for 10 years. Margaret is married and has three children who are in high school. She used to be involved in her local church and loved to play racketball. Her husband’s job is very demanding and most of the care of the home and the kids falls to Margaret  One Year Ago: She has been struggling with her health for several years. She has a Whole Person Risk Score of 104 based upon having multiple conditions, taking several medications, seeing multiple doctors, not being up to date in her preventive care, and not following effective pathways of care for back pain, obesity, fatty liver disease, and depression. In the last year, she used her full complement of sick leave and had to take a few more days off at her own expense. She does have a relationship with a nurse practitioner who she’s seen 4 times in the last year. While she’s had no hospitalizations, she has been seen in the local Emergency Room 5 times in the last year. Intervention Based on the Whole Person Risk ScoreTM the Personal Health Assistant, Sarah, assigned to Margaret reached out to her repetitively for a conversation. Finally, she reluctantly took the call and was pleasantly surprised. The call began the process of building trust and was a positive, supportive conversation where the PHA and she explored how the PHA could assist Margaret in being more successful with her health and well-being. Here is what the PHA learned:  Margaret & Sarah’s 1st Year Journey During the initial 30-minute conversation Sarah listened and asked questions to better understand that Margaret was feeling confused, scared, and immobilized by concerns about how to use her benefits. While she knew that the ER and not working with the NP consistently was not the best way to deal with her problems, she did not know what to do. At the end of the call, Sarah and Margaret set up a second call to review her Personal Health Summary which reviewed all her diagnoses, medications, doctors, procedures, and recommendations to get healthier. After reviewing this Margaret realized that she needed to address these issues and take a different approach. With Margaret’s permission, Sarah shared this comprehensive summary looking at past utilization, and the key steps for the future with her PCP’s office. Sarah and Margaret made a list of the challenges, prioritized them, and set up the next meeting. Over the last year, Sarah patiently walked through the opportunities Margaret’s company offered. Margaret could barely believe all that was being offered and was so appreciative of what she had access to. She signed up for them as the problem they addressed became the priority and between the programs and her primary care doctor (supported by the NP) she gradually overcame them one by one. Margaret started with 2 key goals: to build a connection with her PCP and address her mood challenges. Sarah helped her engage with the employee assistance plan (EAP) to discuss the emotions she was experiencing and get supportive coaching about how to address them and how to communicate what was happening to her doctor. At the same time Sarah scheduled an appointment with the PCP collaborating with the NP she was seeing for an annual exam. These went well and her PCP took her off some of her medications (which had been causing side effects and financial stress) and put her on a mood-improving medication that she learned was both safe and inexpensive. During her initial visit, her PCP did a breast and cervical cancer screening exam and ordered her mammogram and colonoscopy which Sarah helped her get set up and done. At first, she felt a bit guilty that she wasn’t seeing her OB/GYN who delivered her children, but realized that this was time, energy, and cost that her PCP could save her. Her EAP coach helped her identify the key symptoms that bothered her the most and the PCP, EAP coach, and she kept working together until they were 80% resolved. This led to her wanting to be more active. She joined the MSK program offered by her company where again she got a coach. Basic exercise bands and tools were sent to her home, and she began – slowly initially – to be more active and to address her back and knee discomfort. She knew her weight was contributing to her fatigue, sleep, and MSK issues, and after a lot of encouragement from Sarah, she signed up for the weight loss program through an APP offered by her employer and she liked it. Margaret & Sarah’s 1st Anniversary of Working Together As shown in the table, Margaret is in a very different place. With Sarah, she has a trusted companion and coach on her journey who, while not a doctor or nurse, has increased her understanding and ability to use her benefits, the healthcare system, and her medical and medication issues. Her company that funds Sarah saved at least $10,000 on her healthcare as she has become more proactive and much less afraid and reactive. She is optimistic she will be able to work until retirement in 10-15 years.

November 26, 2024: Meet Margaret, a 47-year-old female employee in your company. Read More »

October 7, 2024: Talking about Risk

Clinical Consulting, Employer Healthcare Solutions /

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care If you were to ask someone how they felt right now, most would say … “I feel fine”. Some are fine. They are young and healthy and have little need for medical services. Others respond “I am fine” but they have a number of significant risk factors. They may be diabetic, in CHF, experiencing all forms of distress and they are actually not fine. They do not use primary care preferring subspecialist care. They are not yet having an event that leads them to urgicare, the ER or in for a hospital stay. Others have dropped over the edge some time ago. They are both high risk and high cost. Using data to assess risk and responding effectively is the key. Being able to succeed with your value based proactive paid contracts will require that you and your system get very good at using data to risk stratify and developing processes within your practice that allow you to do the following: First, identify those people who are at high risk Second, create processes within your practice that ensure that staff can identify the risk within the individual patients they deal with each day and be sure that the high risk/low cost receive preferential attention when they contact your office. You want them in ASAP. C Third, your team needs a plan to reach out proactively to these patients, to get them in for a comprehensive visit. These people are the ones who most benefit from Advanced Primary Care. Your team can work miracles. Fourth, you and your team need to understand and effectively respond to the health literacy level of the patients. People’s motivation vary as does their ability to grasp ideas, interpret reports shared with them, etc. Fifth, your team needs to build loyalty among your patients so that they think of you first when they have a health/medical concern. Proactively sharing information that is relevant to them as patients is created “stickiness”. Create an e-newsletter or listserv so you can share materials with them. They like hearing from their doctor. It is easy and inexpensive with a platform like “Constant Contact”. We appreciate that if you are working in a hospital owned practice, the administrators will want to control this. But most administrators focus on marketing and not service. Work with them. Convince them over time.

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September 25, 2024: The Challenge of Complex Care Management Part D

Clinical Consulting, Employer Healthcare Solutions /

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 22 Aligning Care Management Incentives Around Value  Highly effective care management tightly embedded with the primary care team can be tremendously effective in improving patient outcomes.  The converse is also true in most cases we have examined.  Remote care management siloed away from the primary care team is minimally effective by comparison.  We have already demonstrated that high value advanced primary care reduces admissions, ED utilization and total cost of care based on our experience with clients and in our practices where payment was aligned with improved health outcomes and lowering the health risk of our populations.  So how do we measure and incentivize the work of care management nursing to steer toward high value work?  Effective care management nursing is centered on the same factors as the rest of the primary care team.  Trust is the key currency, which is tied to the relationship they can establish with patients over time. Continuity, competency, reliability, and compassion drive the trust relationship forward and this empowers patients to change. No patient will follow the advice of any clinician or nurse they do not trust. Look at every part of the CM RN workflow to ensure that what they are doing builds trust and serves the interests of the patient first over the interests of the system (ACO, hospital, or whoever).   Documentation should be lean and specific so that the rest of the care team is clear on what part of the overall care plan the nurse with working with the patient on.  Don’t consume precious time in make-work processes but invest their time to better understand their patient’s needs and help them navigate the next steps of their care.  We believe that measuring high-risk patient’s trust and engagement with their care managers would be the pinnacle of assessing the value of the work done.  We also want to  measure how the total cost of care and health risk of those high-risk members declines the longer they are engaged by a care management nurse.  Outpatient care management is not just “get ‘em in and out” as many ACO’s have in their “enrollment” metrics.  Simply enrolling a patient, especially if those patients are not target in order of risk, does little to impact cost or improve health risk. We want to encourage gradual transition of patients who are making positive changes back to their care team’s oversight.  Many patients, by the nature of their disease process or social determinants are going to need more help, not less, over time so some will need periodic long-term check ins by their trusted care management nurse to keep tabs on their decline and help them transition to palliative care.    The major difference in care management in the primary care setting from that of inpatient or transitional care management is that the relationship of the patient with their primary care team is longitudinal and often lifelong.  Having metrics that reward short, superficial contact with patients will not yield the outcomes that our patients need, nor will it reward systems with cost savings that allow you to pay for quality care management.  Scott Conard, MD              Michael Tuggy, MD                  Susan Lindstrom                 Laurence Bauer, MSW, MEd [email protected]   [email protected]   [email protected]   [email protected] Kathleen Dalton, RN, CCM, CMGT-BC [email protected]

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September 18, 2024: The Challenge of Complex Care Management Part C

Clinical Consulting, Employer Healthcare Solutions /

Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 21 Entities defining the work We have much to say about pseudo-regulatory companies that create standards and processes for both primary care and care management.  As these companies do not actually take care of patients directly, they are not accountable to real patients or outcomes.  Far too often, these entities focus on process, documentation and frankly, make-work instead on getting direct feedback from patients, clinicians and their care teams as to the effectiveness of the process they promote.  Many clinics and care management departments have NCQA certification, but their patient loyalty, engagement and outcomes are abysmal.  These same care teams have a lot of choice words to describe how the certification requirements impact their work with patients.  “It’s all about checking boxes not about engaging patients in what really matters,” is a common refrain I have heard when surveying care management nurses.  The primary metric needs to be improved patient outcomes measured mostly by patient input and reliable data on utilization of services.    The Person-Centered Primary Care Metric, now adopted by CMS for its MCP and ACO Flex primary care initiatives, is an ideal example of a tool to measure these essential aspects of trust and relationship in primary care.  A simple modification of questions would allow a care management department to get a strong sense of how the patients they engage feel about the effectiveness of their care manager.    The focus must be on building trust first, meeting the patient where they are and developing an actionable care plan that the patient can pull off realistically.  Gather data shouldn’t just be a long list of questions but should involve a care review of the patient’s active problems and apparent barriers to care, then when first contact is made, the care management nurse knows the patient to a depth that instills trust because they have done their homework.  When access care challenges and barriers, the SDOH relevant bits of information will come to light as to what is really impacting that patient.    Care plans are often a disaster if not written in a context of active problems, their interplay on the patient’s life, and setting realistic expectations of things the patient is willing to work on that week using motivational interviewing skills.  A number of consulting organizations generate prebuilt care plans that are so generic and aspirational that they resemble emesis on paper.  They are often lengthy, unrealistic, laden with platitudes, and far too many goals to be realistic.  How about having a diabetic use a pillbox to help him remember to take his medications twice a day?  That may be all that the patient can handle for the next month so perhaps that patient derived care plan should suffice, not a laundry list of ideals that we can generate with a Smartphrase.  It is far better to have lean documentation, a workflow and a real plan of care that is coordinated and in sync with the primary care provider’s and the patient’s priorities.  Care managers can certainly enhance and inform those priorities but neither the PCP nor the care management RN should be creating a plan in a vacuum for a complex, high-risk patient.  Teamwork here is essential and should be a key metric to assess the quality of CM services.  Kathleen Dalton, RN, CCM, CMGT-BC [email protected] Michael Tuggy, MD [email protected] Scott Conard, MD              Susan Lindstrom                 Laurence Bauer, MSW, MEd [email protected]     [email protected]      [email protected]

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