How Payers Can Deliver Value Through Care Management Models

July 11, 2022 - Now more than ever, healthcare consumers are looking for value from their health plans. Traditionally, value has centered on the quality of clinical care and the total cost of care for those services. To achieve value, payers have stood up care management programs designed to reduce expenditures while ensuring accessibility to high-quality providers and services. However, in an increasingly consumer-oriented healthcare environment, payers must also account for member experience when determining the value of their care management programs and plan benefits.

Healthcare consumers are coming to expect more, or at least different benefits from their health plans.

Firstly, more consumers are reaching 65 years of age or older. With a rapidly increasing older population, payers must tailor their care management programs to account for the needs of more senior members. More than two-thirds of Medicare beneficiaries have multiple chronic conditions, according to data from CMS.

Secondly, more healthcare consumers want to manage their chronic conditions and other healthcare needs in their homes. More than three-quarters of adults 50 years of age or older plan to age in place, according to a 2021 survey fielded by AARP. Additionally, consumers have become more comfortable using virtual care methods, such as telehealth, to receive services within the home.

Traditional Medicare offers benefits to manage older adults' chronic conditions and other needs. However, those benefits do not always extend the provider’s office or hospital to member homes, nor do they always meet consumer demands, like coordinated benefits under one plan. Medicare Advantage has stepped up to close those gaps, and the program has been very popular. The Kaiser Family Foundation recently reported that approximately 42 percent of Medicare beneficiaries are enrolled in a Medicare Advantage plan, and that number is likely to grow if enrollment trends continue.

Medicare Advantage emphasizes value, especially around member experience. In fact, experience-related measures will determine over half of a plan’s overall Stars rating by 2023, which is up from 25 percentage points compared to 2020, McKinsey & Company found. Medicare Star ratings are also closely tied to a plan’s incentive payments, meaning member experience is not only key to attracting and retaining members but also a payer’s revenue.

Care management programs must be able to deliver an excellent member experience while meeting the clinical care needs of an older population. These programs must ensure that the benefits provided to ensure a high-quality experience are also the most cost-efficient.

Care management for value

The push for value-based care has gained momentum and payers have developed care management programs to ensure holistic treatment of members to reduce the number of services they need. However, that model is now evolving, according to Ed Motherway, President of CareScout.

“Where that has evolved is around reimbursement from CMS,” Motherway explains. “You are measured on your capabilities to decrease utilization. From a payer's perspective, to get that maximum reimbursement from CMS, they've had to devise methods to keep patients healthier, and this is for all populations. So, you must be flexible, whether you're in rural care or your members want to age in place or whether they have chronic care issues.”

The challenge for payers though is that flexibility is not always possible when it comes to treating all their populations in a value-based way.

“The biggest hurdle right now is scaling these models,” Motherway states. “Payers are not designed to develop these types of care models in the first place. It’s not their culture to make rapid adjustments either. However, the marketplace is demanding these models much faster than the organizations can adjust. So, they must cobble together a model that meets the needs of their population and is effective.”

Piecing together a strategy for care management doesn’t work unless payers can properly coordinate those pieces. Registered nurses (RNs) and clinical assessments can be the key to getting all the pieces to the care management puzzle in place.

Leverage RNs for clinical assessments

Payers can leverage the expertise of RNs to perform high-quality clinical assessments, particularly for members requiring more specialized care for a chronic condition. These RNs can perform clinical assessments in a wide variety of care settings, including member homes and through video. These assessments can not only help payers make more informed risk management decisions but can also benefit those receiving the assessment who wish to age in place or remain at home, as opposed to going into a facility.

“If you are able to do very simple clinical work in the home, perhaps even what might be called preventative care or interventionist type care, which could be education, it could be some sort of monitoring, it avoids those reasons to go to a facility,” Motherway explains. “Because as soon as you get into a facility, that’s when your costs start to rise.”

In-home RN interactions can also support quality and member experience, with nurses gathering meaningful data on members, such as social determinants of health.

To leverage RNs successfully for high-value care management, payers need to maintain an adequate workforce. RNs may also need experience with certain chronic conditions or other diseases if the member populations require that specialized support. But as Motherway points out, payers aren’t necessarily designed to coordinate that type of care management.

“Payers can’t deliver all of these services organically,” he says. “They have to leverage other organizations in order to complete the execution of their care management models.”

A trusted partner can help payers tap into a network of qualified RNs and allow them to scale their care management programs when needed. This can all happen without payers having to do the heavy lifting of hiring and managing a large RN workforce themselves. A trusted and strategic partner will also handle the administrative aspect of leveraging RNs for care management, including billing services delivered through the care model.

“The great value is to put at ease a payer—or organization that works closely with payers—to support these care management programs. To ease their resource demand around RNs and how they can be deployed in these programs,” Motherway says.

RN interactions can improve quality of care and member experience while ensuring appropriate utilization of care and reduced costs. These interactions are vital to care management programs in order to deliver value, and payers will need to incorporate RN interactions into their care models to be successful.

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About CareScout

A trusted leader with more than 20 years of experience, CareScout performs objective, accurate, and timely clinical assessments to help payers make informed decisions. CareScout’s nationwide network of 35,000+ registered nurses and licensed social workers can easily and seamlessly supplement your existing clinical assessment services.

Learn more about CareScout here.