Why Precise, Tailored Patient Registries Lead to Cost-Effective Care Management Programs
Open up any healthcare industry publication or blog (including this one) and you’ll find that care management—evidence-based clinical care activities delivered by a nurse, physician’s assistant or other mid-level professional and designed to help improve health outcomes—has become a hot topic.
Certainly it got a boost this year when the Centers for Medicare and Medicaid Services (CMS) announced it would begin paying roughly $42 per patient per month to physicians for managing the care of Medicare beneficiaries with two or more chronic conditions beginning January 1, 2015. This further validates the benefit of care management as part of an overall population health management (PHM) strategy.
If PHM is the noun for a healthy population of patients, care management is the verb to achieve it. In other words, if the goal is to keep healthy patients from becoming sick, barely sick patients from becoming sicker, and the sickest patients from requiring costly episodes of care, healthcare can no longer afford to be reactive. Instead, providers must apply more proactive interventions, such as patient education, nutrition counseling, telephonic outreach, and self-monitoring devices or apps.
In an ideal world, where time, money, and resources are unlimited, care management services would be offered to every patient on a primary care physician’s panel. In the real world, however, that approach is simply not practical. Which means primary care physicians must apply their limited time, money, and resources where they will deliver the best return on investment.
This is especially true for the bulk of patients who do not fall under the CMS program. At present, most health payers do not pay physicians directly for care management services. Rather, providers participating in accountable care or value-based contracts should invest in care management as a method to reduce their overall utilization. A financially successful care management program must therefore be delivered for exactly the right group of patients for whom we can improve outcomes while reducing overall cost.
That task is best accomplished by building a precise, tailored patient registry.
Challenges of Building Patient Registries
A registry is a collection of standardized information about a well-defined group of patients who share a similar clinical condition or experience. Good registries provide care management teams a focused set of patients to work with.
Care management programs have traditionally been operated by insurance companies, and have usually focused on high-risk patients. These programs have proven effective at improving care and reducing cost, but these programs have two problems:
- They don’t have access to the rich data of patients’ electronic health records
- There is often a meaningful (i.e., 30+ days) time delay between a clinical event and the payer’s awareness of that event
Take the example of a care management program for asthma patients. The payer can see from the diagnosis and procedural codes on claims, which patients were diagnosed as having asthma and which ones received breathing treatments. The payer also knows which patients have filled their Albuterol prescriptions.
The best predictor of risk that a payer has is the cost of care provided for that patient. Unfortunately, cost is a lagging indicator of clinical risk. Traditional care management programs often struggle to identify rising risk patients, which happen to be those patients for whom we can make the biggest clinical and financial difference.
Hospitals and health systems, particularly those using an enterprise data warehouse (EDW), have a much richer dataset to draw from, and thus can create far more precise and tailored definitions of which patients should be included in the care management program. Richer data helps categorize patient populations into high-risk, low-risk, and the ever-important rising-risk groups, which is critical to the success of any population health management initiative.
A precise, tailored patient registry can include patients who have wheezing or shortness of breath on their problem list. The registry can include those patients where the radiologists’ impression of their chest x-ray includes bronchial thickening. A precise, tailored patient registry can stratify asthma risk based on the results of a pulmonary function test, or by those who have been prescribed inhaled or systemic steroids, but have not yet filled their prescriptions. The more tailored an organization can make these patient registries, the more they will be able to ensure they are focusing their limited time, money, and resources where they will do the most good.
Measuring the Effectiveness of a Care Management Program
As the industry moves toward value-based reimbursement, being able to quantify the ROI of a care management program is critical to its effectiveness (and its continuation). There are three basic methods used to measure the effectiveness of a care management program:
- Randomized control design. This is normally the best option as it allows the most precise comparison between creating an intervention and not creating one. With this method the organization builds a precise, tailored patient registry, selects a portion of that group to receive an intervention and then compares the results between the two groups. These studies need to be carefully designed to avoid withholding treatment for patients who need it. Larger organizations can stage the program with a staggered rollout to their facilities and practices.
- Historical or intent-to-treat design. With this approach, the organization can lay out the criteria of people selected for the care management program, compare them to past patients with similar conditions who were not part of the program and measure the difference. Take a patient with asthma who showed up in the ED before the care management program was in place. The doctor wrote an order for asthmatic education materials, so we assume that, had the care management program been in place, the patient would have been enrolled. By closely matching that patient to a current participant in the care management program, the organization can measure whether care management is making a difference.
- Matching comparison design. This is the least desirable approach, but one that is sometimes necessary. In this situation the organization uses the precise, tailored patient registry to look for patients from one employer who isn’t participating in the care management program and matches them to another that is using the program. The biggest challenge is whether the organization has captured the right information to make good matches.
Take the example of two patients who are both 6’ tall and weigh 200 lbs. These two patients have identical BMI but do not share the same risk of heart disease. One of the patients is fit, muscular, and eats well. The other one is sedentary with a 42” waist. It would be a much better fit to select patients for inclusion in a matching comparison if we could select by both BMI and waist size. To effectively use a matching comparison design, the organization must have enough patients with enough data to create an accurate match based on demographics, geography, and sociographics, as well as the condition.
Ensuring Measurement Precision
The accuracy of any of these methods will improve when candidates are drawn from a precise, tailored patient registry. The more specifically the organization can determine which patients should be asked to participate, the better the measurements will be.
Again looking at asthmatic patients, if the organization includes any patients who have been documented with wheezing, coughing, or asthma in the trial, it may be difficult to determine whether the organization is saving money and driving better outcomes. But if it can focus on the sickest patients, and the level right below them, the organization will gain a better sense of whether the care management program is having an impact on reducing ED visits and inpatient admissions/readmissions.
No matter which method is selected, it is also important to take care in how the results are measured. Balanced metrics, as well as outcomes and the cost of operating the program, must be taken into consideration, all of which are data intensive. Here again, an EDW is invaluable in providing analytics to determine the true ROI of the program.
The Future of Care Management
We are in the midst of a transition from payer-led care management to provider-led care management.
Providers have access to the rich, real-time data about their patients that is instrumental in stratifying risk and setting up a population health management initiative for success. Precise, tailored patient registries leverage that data to focus care management programs on the patients that will benefit the most.
Precise, tailored patient registries help accurately quantify the value of a care management program and ensure that a healthcare organization’s limited time, money, and resources are focused where they will deliver the greatest benefit, both to the patients and to the bottom line.
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