Care Management Opportunities and Calls to Action 

Our last payer trends article highlighted the care management sub-market, which is an area where we have extensive experience and created technology solutions. Now, we’re diving deeper to share salient care management trends for 2020 and beyond. 

What’s your take on the care management market? Let us know on Twitter or LinkedIn. 

Care Management Market Size and Growth

The care management solutions market worldwide is projected to grow to $16.9B, driven by a compounded growth of 16.5%. The projected market size is $19.28B by 2023. This market shows healthy, continuing double-digit growth, which covers disease management, case management, and utilization management.

The primary influences compelling growth initiatives are the shift of risk from payers to providers, government programs, and regulations pursuing patient-centric care and healthcare IT, an aging population, as well as the need to reduce healthcare costs while providing higher-quality care that supports patient behavior change.

Care Management Trends Tied to Value-Based Care (VBC) Evolution

We can’t project where the care management space is going without looking at value-based care trends.   

An increase in new risk-based contracting options is emerging alongside proven models like shared savings and bundled payments. While Medicare Advantage-style payment programs continue to be offered, risk-based contracts are looking for networks of high-value providers. 

A 2019 survey released by the National Business Group on Health shared that11 percent of large employers now have narrow-network contracts in place, an increase by eight percent over 2018. A key influencer on this trend will be how employers and providers address geographically diverse workforces who need distributed providers. Yet, this is an area of opportunity as two-thirds of employers plan to steer employees to a differentiated center of excellence for high-volume, preference-sensitive conditions and another 22 percent plan to establish direct contracting networks themselves. 

Shifts in Who’s Doing (will do) Care Management 

Which arm of healthcare that carries out care management has the potential to evolve and shift? As partnerships and contracts change, so too are the hubs and players on the team to carry out care management.

Payers:  

Payers continue to partner around VBC, reporting that 80 percent of health plans have improvements in care quality, and 73 percent demonstrate improved patient engagement with VBC. Aetna, for example, has created provider partnership that achieved $9.9M in shared savings over three years and an 11.5 percent reduction in medical costs. Strong care management capabilities are one of the three criteria that they require. While UnitedHealthGroup is buying up primary care clinics and ambulatory surgery centers as one path to manage costs, creating their narrow networks, payers are partnering with retail increasingly.  

Also, Aetna is looking to provide less of their care management via call centers and creating models that more closely align with health systems and physicians. They will look to doctors at the point of care to use payer information to identify gaps in care.

 Providers:  

In contrast to payers, one-third of providers report a positive return on investment on VBC over the past five years. One viable approach by providers innovates by managing the total costs of care through launching their own insurance products and partnering with payers or employers. They may create an integrated, high-value network, or they may use a care management program as a leveraging chip when demonstrating population health outcomes. Some are looking into “stem-to-stern management” contracts as well.  

Providers are also creating more service offerings through retail. Providence Health & Services is embedding 25 clinics in Walgreens stores in Oregon and Washington, as well as opening 25 freestanding walk-in clinics. These clinics will eventually offer chronic care management. They’re also launching employer-based, on-site clinics. All of these evolving models of care delivery offer opportunities to provide a variety of care management capabilities at the source of population needs.

Community:

Community care management is a future model of care management that is emerging as a way to put patients at the center of care while monitoring and maximizing factors like consumer-centric behavior, work-life balance, population management, and outcome data. In this approach, the focus moves beyond the individual consumer to the community with the intent to provide accountable, coordinated, whole-person care that involves the hospitals, as well as clinics, home care, caregivers, and community support. This could support a shift from hospital-based care to residence-, community-centered care. Community budgets will be established for a particular target population with shared risk strategies between providers and the community, accelerating a shift from volume to value.

Physicians:

According to key findings by Stanford, physicians-in-training, residents, and students expect that almost a third of their duties could be automated in the next 20 years. Nearly half of all physicians (47%) and 73 percent of medical students are currently seeking out additional training to prepare for such innovations in case, including advanced statistics, genetic counseling, population health, and coding.

Nearly half of those same medical professionals wear a health monitoring device. Those who do say that they use the data to inform personal healthcare decisions. And 80 percent of those physicians say that self-reported data from a patient’s health app would be clinically valuable in supporting their care.

Highest Value of Care Management Comes from Grads, Not Engagement

Recent research published by HFMA said that high-risk patients enrolled in Medicare, who completed care management programs, have substantially better outcomes and lower spending than those who are not involved in care management. Across three full-risk accountable care organizations (ACO), the impact of care management was $15.1M, more than half of the $26.6M in shared savings for the three ACOs.

Monthly costs for patients who graduated from the care management programs were 22 percent lower than those who did not graduate or didn’t use the program. In fact, when patients engaged with care management but didn’t graduate, their spending was nearly identical to those who’d never joined.

Interoperability as Keystone to Care Management & Population Health

Over half of payers are not satisfied with their current value-based analytics, automation, and reporting capabilities, highlighting the need for clinical analytics. Over 70 percent of healthcare financial executives say that data interoperability must improve within two years for VBC to succeed. In 2019, one of the foci was ensuring that everyone across an organization’s ecosystem could have access to comprehensive individual and hospital-wide data.

Social Determinants of Health: Making Progress but Major Gaps Remain

Organizations are expanding their appetite for social determinants (SDoH), but many still struggle to advance far enough. It’s quite common for a hospital to take the first step, screening for SDoH. More than half the EHR market had launch screening tools within their systems in 2018. However, many health systems are challenged with the three main steps around social determinants – gathering data, identifying a need, addressing the need by connecting with support, typically, in the community. For example, during one pilot program, 38 percent of the first 1,000 patients screen had at least one high-risk need related to SDoH. Additionally, a survey of 300 hospitals and health systems found that 9:10 screen patients for social determinants, but only 62 percent screened patients systematically or consistently.

The goal is to automatically connect patients to appropriate community or in-house resources and study how those connections support ED visits, education adherence, and appointment no-show rates.

Getting referrals into the community is a significant hindrance. Thirty-one percent of US PCPs said that a lack of referral system was a significant challenge for coordinating care. Even if a care management element was connected and available, taking the need from identification through to resolution and follow-up requires more connections and technology.

Services, like Aunt Bertha and NowPow, are emerging startups that connect hospitals with social service programs. This highlights a sentiment revealed again and again; “If we can’t address the need, why should we raise the issue?” An AAFP survey revealed that 80 percent of family physicians feel that they don’t have time to discuss social determinants, and 64 percent did not believe that they had the staff or resources to address needs once discovered.

Market & Care Opportunities for Care Management

Maternal Care Needs Care Management

While shocking, the US is reported to have some of the worst maternal health outcomes in the developed world. A new care model of maternal and infant health is heralded, and VBC and care management could make a major, positive impact. Commercial insurers like UnitedHealthcare, Humana, and Cigna have announced programs to test maternal health bundles in specific markets. These bundles could include primary and obstetric care through to 60- or 90-days postpartum, and encourage providers to collaborate across settings and stages of a woman’s health. For 2020, it’s possible to see the launch of a national demonstration of maternal bundles through the Center for Medicare & Medicaid Innovation.

AI and Machine Learning Helping Identify Chronic Care Conditions

Artificial intelligence (AI) and machine learning are being used to comb population health data to make connections and identify chronic conditions that could require care management. Published in PLOS One, a study used a machine learning algorithm to mine EHR data and discover associations between common chronic diseases and lesser-known conditions. Another study, published in Circulation: Heart Failure demonstrated that using artificial intelligence to identify worsening heart failure, combined with a wearable device, could predict critical changes in heart failure patients with a level of accuracy on par with implantable sensors.

Employers Ramping Up Chronic Care for Cost Savings

The Employee Benefit Research Institute found that, from 2013 through 2017, one-third of people who were persistently in the top 10 percent of claimants had diabetes. More than half of those also had hypertension, and about a quarter had respiratory disease, back problems or connective-tissue disease. More employers are picking up where traditional chronic care management seems to be falling short.

Many large employers plan to prioritize monitoring and managing high-cost claimants through case management, health advocacy, and concierge services. January 1, 2020, Walmart rolled out a new health care plan with a care management models in certain states.

Ambulances Extending Higher Levels of Care into Community  

CMS launched its Emergency Triage, Treat, and Transport (ET3) model in January, giving ambulance teams greater flexibility around where and how they deliver emergency care to Medicare beneficiaries. The voluntary model will expand payment beyond direct transport to include alternative destinations. This could open up another opportunity for care management as services in the field can connect and re-route based on need.

What Did You Find Intriguing in the Care Management Trends?

These trends give a smattering of some of the latest research and news. Our healthcare services team can help you make sense of these trends and what they’re seeing in the market for care management programs, models, and technology.

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