How Care Management Improves Performance for Clinicians, Compliance with MACRA, and Outcomes for Patients Like Olivia
As Olivia left the office, Dr. Roberta Pelz was worried. Olivia had always struggled to manage her diabetes and congestive heart failure, but as she approached her 70th birthday, the situation seemed to be getting worse. Her hemoglobin A1c, a marker of diabetic control, was constantly around nine (ideal is less than seven) and her heart failure was, at best, borderline controlled. Based on caring for Olivia for many years, Dr. Pelz knew the problem was related to Olivia’s ability to comply with her medication regimen and dietary restrictions.
Dr. Pelz’s concern went beyond Olivia’s welfare. She had many chronic disease patients like Olivia in her panel of patients, and they all represented a care management challenge. In addition to individually managing these patients, now Dr. Pelz had to worry about her overall performance in managing patients like Olivia because of the growing emphasis Medicare placed on outcomes and the increasing link between performance and reimbursement. In fact, Olivia embodied two of the chronic disease states (diabetes and heart failure) that Dr. Pelz had decided to focus on to comply with the Medicare Access and CHIP Reauthorization Act (MACRA).
How MACRA Impacts Care Management and Why Performance Improvement Is Key
MACRA, signed into law in April 2015, does several things, but most importantly it establishes new ways to pay physicians who care for Medicare beneficiaries. MACRA fundamentally changes how Medicare reimburses for clinical care by introducing two payment tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).
Most providers are expected to fall into the MIPS track. MIPS represents a new payment mechanism that will provide annual updates to physicians starting in 2019, based on performance in four categories:
- Resource use
- Clinical practice improvement activities
- Meaningful use of an EHR system
The goal of the program is straightforward—encourage physicians to focus on the one thing that matters most to patients: making them healthier.
Dr. Pelz had been involved in clinical improvement efforts in the hospital, most notably improving the diagnosis and treatment of diabetic ketoacidosis (DKA), a common diabetic complication requiring hospital admission, and preventing heart failure readmissions after discharge. However, MACRA requires her to focus on optimizing care of her chronic disease patients across the continuum in the inpatient and outpatient environment. To optimize care for patients like Olivia, she had to find a way to extend her reach beyond care encounters in the clinic and hospital to manage Olivia’s care more continuously.
Improving Outcomes for Olivia Through Analytics and a Multidisciplinary Approach
Because Dr. Pelz was aware that the local health system was developing a care management program as a part of their population health management strategy—managing a selected set of patients to focus on reduced cost and better quality of care—she set up an appointment with the Chief Medical Officer. At the meeting, she was surprised by how much progress had been made.
Powerful Analytical Tools
Powerful analytical tools had been put into place that made it easy for Dr. Pelz to identify patients in her panel that would benefit from better care management, including the ability to stratify them by risk and need. It was not surprising to find Olivia was among those patients. The analytical tools also made it much easier for the care team to collaborate and coordinate care for chronic disease patients, and monitor their progress over time. Patients who were doing poorly and at high risk of being admitted could easily be identified, allowing the care team to redouble their efforts to improve their outcomes.
A Multidisciplinary Approach
Specially trained nurse care managers had been hired to work with physicians and other members of the multidisciplinary care team. Dr. Pelz immediately recognized that she could utilize this program to care for Olivia beyond solely encounters in the clinic or hospital. The care managers could help coordinate all available resources to manage chronically ill patients, including specialists, ancillary providers like educators, dieticians, pharmacists, and community support resources. This multidisciplinary care team approach would allow her to broaden the support that patients like Olivia received and more easily engage both patients and their families in their care.
As she reviewed her list of “at-risk” patients, Dr. Pelz saw a common theme. Like Olivia, most of them were non-compliant with medications or diet. Several factors influence medication and dietary compliance in older adults, including unclear instructions, inadequate education, medication cost or side effects, lack of patient and family involvement in the treatment plan, and the complexity of the dosing regimen.
In 2003, the FDA highlighted a study that demonstrated between 40 percent and 75 percent of older people do not take their medications at the right time or in the right amount because of complicating factors, such as the number of medications prescribed and the number of providers seen for multiple health problems, as well as other physical and cognitive challenges. Lack of understanding of their illnesses and the role medicines play in their long-term management can also lead to medication non-adherence. In Olivia’s case, several of these factors were in play.
Working with the care managers, Dr. Pelz launched a plan to improve medication and dietary adherence for Olivia and other patients like her. The care manager established a supportive and trusting relationship with her chronically ill patients. Whenever possible, generic medications were used to control costs, medication regimens were tailored to each patient’s daily routine, and clear, written instructions on how to take the medications were provided. Qualifying patients who were not enrolled in Medicare Part D were entered the program to help them address drug cost challenges. Reminder strategies tailored to each individual patient, like pill organizers, calendars, and phone reminders, were introduced. Each patient was educated regarding what to expect, including how the mediation works, the goals of treatment, and how to monitor effectiveness. Dieticians provided education on the appropriate diet. Family members and support groups provided social support. With these measures, Dr. Pelz was pleased to see most of the at-risk patients in her panel improve over the next six to nine months.
Care Management Improves Population Health, One Patient at a Time
It was clear that the comprehensive care management program was having a significant impact and improving care for Dr. Pelz’s chronic disease patients. In short, the program made it far easier for her to coordinate care for her patients and improve their lives. She could be the best she could be in service to her patients—the reason she went into medicine in the first place. Importantly, compliance with MACRA became a byproduct of the improved care the care team was providing.
A comprehensive care management program can improve population health, one patient at a time, while also facilitating the spread of best practice throughout a population of patients.