Health reform is changing the landscape of a patient’s care and treatment, and with the increasing prevalence and rising costs of chronic and complex diseases in the United States, key stakeholders — including payers and providers — are now searching for better ways to manage these conditions.
That’s why in April, the California HealthCare Foundation conducted a survey and analysis on how we can start putting together this “complex puzzle” of disease management and complex case management. (Full disclosure: The author’s employer, Booz Allen Hamilton, was contracted to work on the survey.)
Our question: How have disease management and complex case management programs evolved to improve coordinated care and provide the right information to care managers and providers for patients with high-acuity diagnoses?
Take, for example, a newly-diagnosed 50-year-old man with Type 2 diabetes. How would he benefit from a disease management program where a trained health coach works with him to understand the behaviors, health status and other risk factors impacting his care and treatment?
The team conducted a series of interviews with both public and private payers about how their programs — disease and complex care — were arranged; how they targeted specific conditions; and how they evaluated a program’s impact. The assessment revealed that while these programs are not new (providers have been experimenting with ways to help patients manage and monitor diabetes since the 1980s) their success in managing conditions and controlling costs has been varied.
But in light of the key drivers — surging healthcare costs and the frequency of chronic disease — disease management and complex case management will continue to be a critical strategic lever for payers.
In the 21st century, healthcare payers must look to new and innovative ways to improve overall patient care and engagement beginning with better uses of data analytic tools used to drive new insights.
With these tools, payers can process information — like claims data, clinical information, and real-time hospitalization data — to identify the right patients, and then improve the efficiency of their treatments by engaging them with a wide range of patient outreach and engagement tools, like mobile applications, text messaging or in-person coaching.
Payers can also work strategically with providers as partners in the care management of their patients providing tools to better identify patients at risk for avoidable and unnecessary healthcare use.
The future of healthcare is shifting, but through a rounded process of identification and engagement we can better integrate a payer’s disease management and complex case management programs into providers’ practices — all leading to better-quality care.
Susan Philip is a Lead Associate with Booz Allen Hamilton’s health care market and is based in San Francisco. Her client work includes supporting hospitals and health systems, employers, and large public and private purchasers with issues such as quality of care, performance measurement, and strategic planning. Her experience spans health policy, health care finance, public health, and health services research within federal and state governments, academia, and the nonprofit sector.
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