Does Hiring A "Care Coordinator" Assure Care Coordination?

Apparently not.

That's the Disease Management Care Blog's main take-away after reading the Care Continuum Alliance's "Population Health Management in Physician Practice: A Call to Action."

The CCA commissioned a survey that asked 105 primary care physician leaders about the implementation of population health-based care coordination in their clinics. The clinics were from all regions of the U.S. and ranged in size from 5 to 95 physicians (a total of 1,916 physicians with a mean of 18).  To be included in the survey, they had to be planning or had already implemented patient-centered care initiatives, many of which were modeled after the medical home. 93% already had an electronic record and10% reported being part of an Accountable Care Organization (ACO).
 
First the good news.

Over and beyond hiring non-physician providers (96% had at least one nurse practitioner and 70% had a physician assistant), 91% reported that they had hired a "care coordinator."  What's more,  85% said that population health was conceptually important in their practices and the majority 55% rated this as either a "4" or "5" on 1 to 5 scale.

But the bad news is that less than half were familiar enough with the concept to fully implement it in clinical practice.  The number one challenge in this area was the difficulty in making sure that roles and responsibilities of the care coordinators were appropriately defined. 

It should be noted that the practices surveyed in this report were not typical of primary care,  where experience with care coordination is even lower.  This was a elite group of innovators on the cutting edge of primary care who had committed precious resources and already were hiring care coordinators. Yet even these select clinics risk being operationally stymied by not knowing how to effectively implement it in their practice settings. 

The CCA report appropriately concludes with a call for education, tools and support to help physicians fully implement this in their clinics.  The DMCB wholeheartedly agrees.  Based on this report, hiring care coordinators is certainly necessary but isn't sufficient to attain high quality population health.

We still have our work cut out for us.

Big Data and the Coming New Value Proposition for Disease, Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows it's not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

It's "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods you've bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors don't get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is it's next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from refuse to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.

A Money Back Guarantee in Health Care? You Bet!

Who cares about the color, so
long as it catches mice?

Talk about disruptive.

While an unholy alliance of CMS mandarins, fawning think-tank supporters and earnest academics continue to promote their top-down "mainframe" health care ideology, along comes AMCHealth and their money back guarantee.

While the Disease Management Care Blog can only speculate on the how the contracting details would work, AMC's fundamental value proposition is pretty compelling: it promises it will reduce a client's hospital readmissions by "at least 10% within 90 days of deployment" or your money back. AMC is confident it can use interactive voice response (IVR) technology and nurse case managers to identify and then help at-risk patients who might otherwise have to be rehospitalized when things are not going well.

In the meantime, the prevailing Washington DC health reform ideology is that hospitals, doctors, nursing homes and community organizations large and small should pool and sort existing resources under the twin banners of integration and coordination. Mix the solar power of CMS' innovations, the fiscal wisdom of the White House's insurance experts, the academisphere's eternally funded prospective research studies and politically targeted community grants and, if the Feds have their way, the nation's health care non-system will morph into large regional and regulated utilities. Twenty percent of the national GDP will be under the firm control of CMS.

Maybe the DMCB is being overly suspicious. That being said, many of the academics, regulators and government long-timers who are presiding over the medical-industrial complex have made no secret of their disdain of outsider-run care management to the DMCB in meetings and conversations. Using Deng Xiaoping's famous observation, they want their cats to be only one color.

The entrepreneurial AMCs of the health care world are a threat to that vision.  Not only are they a viable business option for impressive organizations like this, they've backed up their claims in the peer-reviewed literature.

If these for-profits succeed, the mainframe healthcare ideology could go the way of dinosaurs, FEMA and Amtrak. By offering solutions that are faster, cheaper and guaranteed, the ultimate success for health care institutions won't lay securing local monopolies but the decentralized and organic business approaches with a mix of build or buy being used in other sectors of the economy.

Image from Wikipedia