Background
To stem rising health care costs, many experts say the nation must focus on the small proportion of patients who account for a majority of health care expenses. These individuals not only have multiple or difficult-to-treat medical conditions but also have behavioral health problems or face serious socioeconomic challenges. Research has shown that specially trained complex care management (CCM) teams can improve outcomes and reduce costs for such patients. In a New England Journal of Medicine Perspective, Clemens Hong, Melinda Abrams, and Timothy Ferris discuss barriers to adoption of a CCM approach and ways to manage them.
Challenges of Adopting Complex Care Management
The most significant barrier to CCM adoption is the fee-for-service payment system, say the authors. CCM is not easily separated into distinct services, and even when it is, most of the services are currently not reimbursed by insurers—thus leaving providers with little incentive to use them. Moreover, if CCM programs are affiliated with hospitals, the reduction in hospitalizations can create a financial disincentive. Additional barriers to CCM adoption include a lack of capital for start-up costs and unrealistic expectations of achieving savings in the short term.
The preferred payment model for CCM, according to the authors, is a global-payment or shared-savings approach. But hybrid models—for instance, where payers offer a care management fee to cover the costs of services in conjunction with fee-for-service—also can work.
While CCM may seem beyond the capacity of small and medium-sized physician practices, many can build such programs by sharing key resources like patient registries, CCM staff, and health information technology. High-quality, standardized CCM training for care managers and other team members is important as well, as is the need for algorithms that can accurately identify high-need patients.
Conclusions
Although increased adoption of CCM will require new policies and practices, it can be achieved without increasing the total costs of care. “Successful CCM not only pays for itself, it also directly addresses our tripartite goal of lower costs, improved care, and improved patient experience,” note the authors, who add that more evidence of the savings possible from CCM programs is needed.