OM: How Does Case Management Fit Into The New Model Of ‘Whole Person’ Health?

NYAPRS Note: Another thoughtful piece from Open Minds. “Health plans should not be the provider of care coordination at the local level. We know health plans want to control costs and they may have concerns about the care coordination and services recommended at the local provider level. However, health plan care coordination adds another needless layer for the consumer to navigate in an already fragmented and incoherent system. Care coordination is a core competency of community mental health centers (CMHC) and CMHC’s will continue to be ethically compelled to provide care coordination as needed at the community level.”

 

How Does Case Management Fit Into The New Model Of ‘Whole Person’ Health?

byRobert Cartia Open Minds July 11, 2016

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Last week, I took a look at the financing and delivery of case management services – a system that seems to be in a state of flux as payers and provider organizations consider the increasingly important role of case management in caring for consumers with chronic, complex conditions and how those services can best be delivered and managed (see ‘Community Behavioral Health’ Without Case Management).

These developments have led to some interesting discussions by our team – and after I shared my perspective last week, my colleague andOPEN MINDS CEO Monica E. Oss asked some very pointed follow-up questions. I thought I would share our conversation about the changing role of case management in the era of coordinated care:

Do you see the traditional “targeted case management” as fitting within a “whole person care coordination” program?

Short answer; yes. Sometimes it seems that terminology, definitions, and models of care prevent forward movement in service innovation. Whole person care coordination is a broad integrated care approach intended to view care to meet the specific needs of each individual and is a byproduct of the Patient Protection and Affordable Care Act (PPACA). Therefore, it is difficult to view targeted case management (a Medicaid term for coordination for specific populations of high utilizers of health care) and whole person care coordination as mutually exclusive.

Do you think the “whole person care coordination” programtrend is a good one for consumers?

Yes. The behavioral health service system has evolved to a point where care delivery is structured such that specific programs provide comprehensive care coordination to individuals or targeted groups. We know that the impetus for this transformation is to reduce cost for high utilizers of health care per the Triple Aim. In my experience, I’ve seen this transition occur in full force in the early 90’s with the emergence of managed care for behavioral health; now, we’ve advanced to the development of integrated managed care entities promoting integrated health homes.

Although cost reduction is the driver for these intensive services, coordination of care and collaboration with community partners is to a great degree the key for successful consumer outcomes. It is important that the care/case coordination is an imperative component of care.Care coordination is unique to the consumer and the community the consumer lives in. The consumer is better served by having a designated person or team to help connect them to services or community supports that will give them the best opportunity to enhance their recovery and prevent out-of-home care.

Do you think that funding the “whole person care coordination” programs via a per member per month (pmpm) is a good idea?

I think of patient-centered care in terms of my experience of providing services to high-risk, high-cost Medicaid populations (consumers with serious mental illness (SMI) or addiction, children, etc.)under a risk-based capitated reimbursement model for the last 20 years.Certainly for children and SMI populations, care coordination is at the heart of how these populations are treated.Obviously, the dollar amount of the pmpm rate is key, but in my experience the capitated reimbursement structure allowed us to manage the care at the local level with the managed care organization (MCO) providing supportive oversight.I think the pmpm payment method can promote outstanding care coordination activities.

We know that payment reform continues to move to outcome/value-based incentive methods. Payment systems vary widely with significant experimentation. But at a basic level, a pmpm with perhaps a value-based component is common. For a period of time, my organization had a contract with a Medicaid health plan whereby they provided a “premium” rate for every enrolled SMI client that we served in our integrated care program. The health plan viewed the integrated model as a means to reducing the cost of care to their patients experiencing SMI. This arrangement occurred several years ago but I think of it as a precursor to the value-based purchasing models currently being discussed.

Do you think that health plans should be the provider of “whole person care coordination” program?

Health plans should not be the provider of care coordination at the local level. We know health plans want to control costs and they may have concerns about the care coordination and services recommended at the local provider level. However, health plan care coordination adds another needless layer for the consumer to navigate in an already fragmented and incoherent system. Care coordination is a core competency of community mental health centers (CMHC) and CMHC’s will continue to be ethically compelled to provide care coordination as needed at the community level.Health plans and MCO’s should review and coordinate care at a macro level and reimburse providers for doing what they have done exceedingly well for many years; provided case/care management.

If you’re a community-based provider organization, and this is happening in your state (like in Florida or Iowa), what is your strategy recommendation?

Perhaps there is no good answer. My state of Arizona took this approach some years ago and eventually found out that they could not adequately provide the case management services and maintain the staff, especially in rural areas, so case management was moved back to the providers. What we did was work within the new model and work with NAMI, our state trade association, and our MCO to help them see that the community providers still had to coordinate care with system partners but were no longer reimbursed to do so. The MCO case managers simply dried up. Providers are going to have to quickly size up the MCO’s determination and realize that the Medicaid space is a funding stream always subject to political preference.

For more on fitting your organization into this developing system and developing the performance of your business development investments, join my colleague and OPEN MINDS senior associate Steve Ramsland, Ed.D. at The 2016 OPEN MINDS California Management Best Practices Institute, for his session “Optimizing Your Business Development Budget: How To Develop A Focused Plan For New Contracts.”