Redesigning Care Models from a Provider’s Perspective

Fragmented, uncoordinated care remains a bane of the U.S. health care system.

Certainly, health systems, hospitals, and medical organizations have made strides in offering ancillary care support, such as social workers to help patients, primarily after treatment. However, the current model depends on care management infrastructure and services that work around providers, rather than integrating with them.

This model has demonstrated its clear limits for reducing utilization, lowering costs, and managing populations and total care costs. The shortcomings are bound to worsen as more provider organizations accept downside risk.


Provider integration is key

Taking the next leap forward in population health management and global risk demands truly integrated care teams that engage and optimize physicians and other providers, not care management and wraparound services that work around them.

What does a care model that appropriately leverages provider knowledge and experience look like? There are four key differentiators to an integrated care management model with providers at the center:


1. Useful data to support timely decisions.

It is essential that providers and patient care teams have the same, complete picture of the patient. This information will serve to more fully engage providers across the care continuum, in part by making it easier for them to identify and track members who could benefit from more services, including help with addressing social determinants of health (SDOH). Successfully managing populations relies on this information for proactively reaching out and monitoring higher-risk patients as well as conducting more effective patient visits.

Providers shouldn’t have to scrounge for this data themselves.

  • Extracting, analyzing and presenting claims and other data in a pragmatic format, especially of outliers and other high-need, high-risk patients, should be a major responsibility of network relations, physician relations and/or the physician transformation team.
  • It also requires a dedicated data analytics team that can keep up with demand in a timely fashion or outsourcing this key function to a specialist firm.
  • Information must be easy to access and understand, ideally fitting into the providers’ existing systems and workflow, rather than requiring a new log-on or tool.


2. Provider education.

Trained largely as autonomous decision makers within a relatively narrow clinical scope, primary care physicians, specialists and other providers need practical advice and education in three key areas:

  • How to use data to manage populations to improve member outcomes and health
  • How to integrate into a care team
  • How to manage total cost of care

It starts with learning and becoming accustomed to new workflows, tools, protocols, AND responsibilities to drive behavior changes. With the wider purview of population health management, providers need to understand how to identify and handle behavioral issues, SDOH, and other not-strictly-clinical concerns. As a result, they must record these broader issues using designated categories and codes in patient records, to build a total view of the patient, to meet quality and other metrics, and to be paid properly.

They also need education on finances, costs, compensation and incentives. While the information and analysis can be produced for them, providers must learn how to review claims, benchmarks and other data to understand and manage care costs, pinpoint areas for performance improvement and track changes over time.

In addition to lowering resistance by giving providers the knowhow to succeed in an integrated care model, standardized provider training can help organizations improve care consistency and quality while lowering total cost of care.


3. Enhanced and aligned physician compensation and incentives.

A major reason that value-based care has not progressed farther or faster is because of inadequate compensation when physicians are asked to do more or act differently. (For a full explanation and solutions to this sticking point, please see Truly Aligning Physician Compensation is Key to Succeeding at Value-Based Care.)

While most payer contracts and government programs now cover expanded care management, the trickledown in shared savings or other incentives hasn’t been enough for primary care physicians and other providers to take on major new responsibilities or transform their practices. To fundamentally alter how physicians manage their patients, compensation needs to:

  • Move from episodic and transactional to relational and longitudinal methodologies
  • Be based on full capitation, risk-adjusted panel size and as if all patients are risk-adjusted and capitated
  • Provide incentives based on new value creation through improved quality and efficiency.


4. Willing and engaged members.

It will take a collective, coordinated effort from the integrated care team and their provider organizations to identify high-risk, high-need patients and keep them engaged and on track. Engagement efforts can range from phone calls to individual patients to offering educational sessions for specific diseases. Provider and payer organizations can also try out and then evaluate different member incentives for adhering to recommended preventative care including annual physicals or colonoscopies.


Leveraging the redesign of the care model

Once providers are more engaged and financially aligned, organizations can begin to more effectively address cost and quality issues. They should:

  1. Assess their current state.
  2. Build a plan to tackle specific goals, such as increase compliance or reduce overutilization of hospital stays and emergency room visits.
  3. Educate and get buy-in on the plan from the stakeholders.
  4. Introduce the plan to entire organization.
  5. Roll out the plan, then evaluate and refine as needed to achieve the goals.

Any new care model needs to make the best and highest use of the skills and experiences of each team member, especially the providers. While physicians and providers cannot and should not be expected to handle all care services, cutting them out or working around them only leads to suboptimal, disjointed care. Primary care providers in particular are ultimately responsible for the members attributed to them, and therefore they must be integral to any and all population health models for the benefit of patients, providers, payers, and provider organizations.

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