What To Expect in 2017: Managed Care Year in Preview

Care management: Taming too much of a good thing


Jan Greene

The Advisory Board recently tracked some patients getting out of the hospital and asked them how many medical follow-up calls they got after returning home. Three? Five? Nope. On average, they had 9.5 calls from care managers from the hospital, their primary care doctor’s office, the insurance company, the emergency department, and others concerned about how they were doing.

On average, patients just discharged from the hospital had 9.5 calls from care managers. (Advisory Board)

Most of the calls went unanswered, says Dennis Weaver, MD, chief medical officer for the Advisory Board. “In many cases they let the phone ring and let the answering machine pick up,” he says.

Care managers are being dispatched by an increasing number of health care entities that have an interest in keeping chronically ill people’s hospitalizations down, particularly if those entities take on financial risk. These now include an array of unexpected players, such as pharmacies that get paid for a group of patients based in part on whether they take their medication. So they hire a care manager who will call the patient and ask.

While these population-health efforts may be well-intentioned, many people in the population-health field acknowledge that the crowd of care managers assigned to track high-risk, high-cost patients has gotten out of hand. “There is a whole host of eager and often relatively inexperienced care managers descending on patients now in many care settings,” says Peter Boling, MD, an internal medicine specialist in Virginia who develops care models for geriatric and advanced chronic care. “It’s inevitable those folks are going to trip over each other. They also contradict each other sometimes, and have conflicting vested interests. It’s obviously inefficient, but more than that, it’s dangerous and confusing.”

The problem is starting to get enough attention that 2017 could see some progress in improving coordination. Both Weaver and Boling contend that a primary care clinician should take the lead on care management.

In the Advisory Board’s survey of discharged patients, the one call that got returned tended to be from the primary care doctor’s office. Because the primary care provider usually has the greatest trust and connection with the patient, it makes sense for her or him to be first in line on care management, Weaver says. For people with serious chronic illness, Boling would like to see that provider be someone based in an advanced medical home that is integrated with a payer.

The PHSO (Population Health Services Organization) acts as a coordinator of care managers, with a common plan and data store.

The Advisory Board saw this problem coming in 2015 and, as consultants are wont to do, devised a solution that creates yet another layer of administration but is intended to reduce overlap and redundancy. It calls the model a population health services organization (PHSO), and the board has been offering it to clients for a year or two. The PHSO takes the lead on care coordination, offers all of the care coordinators assigned to the patient a common care plan, and provides data analytics capability to further refine care. The model is meant to be flexible enough to “plug and play” various providers into the care team as needed so that, for instance, if a patient is referred to palliative care, the palliative team’s care manager can be part of a coordinated team that’s already been working with the patient.

While coordination is intended to be team-based, it still may require some entity to give up some control of the patient, and that can be difficult when dollars are at risk. A PHSO is typically housed within a provider organization of some kind, but often will partner with a willing health plan to coordinate care.

Over time, Boling believes, as the health care industry shakes out with more consolidation, the proliferation of care coordinators will probably work itself out. But until then, patients may continue to see an ongoing parade of concerned nurses and social workers. “Everyone is trying to save the same $10,” he says. “We’re in a typical evolutionary process where everybody has launched all of the boats and they’re bumping into each other. It’s a mess out there.”