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The Evolution of Care Management – Managing Patient Outcomes and Costs

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How Payers and Providers are using Population Health Management to improve patient outcomes and manage costs.

According to Markets & Markets, the largest market research firm worldwide:

“The population health management market is projected to reach USD 42.54 Billion by 2021 from USD 13.85 Billion in 2016, at a CAGR of 25.2% in the next five years (2016 to 2021). “

It only makes sense that Payers and Providers must collaborate as they are at the forefront of this movement.

How Care Management used to work….

Let’s have a look at how care management systems developed over the last couple of decades. Before the Affordable Care Act, which made a huge impact on the industry, payers were the ones who cared more about managing the health of populations because they had the greatest monetary risk. They needed to manage the patients on the top of their pyramid who were costing them in excess of 70% of their total expenditures and so, the Care Management Market was born.

With the Payers at the helm, Care Management worked as follows:

  • Member Claims were analyzed reactively to assess risk
  • The employers of these people would be notified if they had a disproportionate amount of high risk people
  • Proactive and preventative programs would be put into place to manage and counter the risk
  • Payers invested a great deal of money and resources towards infrastructure which would support individual patient engagement
  • Employers shared the costs of the risk mitigation in support of the Payer’s efforts

The evolution of Care Management – next steps….

After payers and providers had squeezed as much blood from the old Care Management Model (stone) as possible, they started looking for disruptive ways by which to leap to the next level and better manage their revenue cycles, so then came:

  • Value Based Management
  • Population Based Management
  • Accountable care

These approaches required the accumulation and assimilation of a great deal of data in order to be effective so, where do we get the data? Well, for one thing, it needs to be “real time” data from EMR and HIE vendors who have connected to providers and payers. Now, the challenge is to integrate the data effectively.

Next step?

Providers and Payers need to work together closely creating solutions and systems which will promote real time dissemination of data resulting in genuine value based patient outcome management.

In addition, payers and providers need to work harder than ever before to manage healthcare spending and make care more affordable for patients and our taxpayers. These new models of reimbursement coupled with more effective care management strategies will enable the stabilization of runaway healthcare costs.

I welcome your thoughts and opinions.

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