01 Dec Should a PPS Set Up a Hybrid Care Management Organization (CMO)?
Samir D’Sa, Principal, NY DSRIP Services and Charles Baumgart, MD, Senior Medical Director, December 1, 2015
It is always prudent to have some risk mitigation when taking on large risks. It’s no surprise then, that health insurers have armies of actuaries (price risk) and care managers (health risk) leveraging sophisticated data, tools, and best practices to manage population risks.
The NY DSRIP program is a step on the journey toward transferring outcomes risk for Medicaid (and the uninsured) to providers. While Performing Provider Systems (PPS) don’t become health insurers overnight, there is an unmistakable shift occurring in their risk profile. For example: PPS’ that don’t meet targets (e.g., A1c goals, care plans, ED and readmission reductions) will see smaller checks from the Department of Health starting in 2016. The magnitude of withholds linked to outcomes only increases with time. PPS’ are expected to engage in meaningful, value-based payments with managed care organizations – and we don’t mean upside only, quality-bonus contracts!
Emerging thinking at PPS’ on how to mitigate this risk takes a few forms:
- Deferral – “P4P isn’t till year 2 or 3… why worry about it now?”
- Delegation – “Our role is to distribute the funds and hold partners accountable.”
- Hybrid – “Our PPS-staffed care team will augment existing care management resources in the county – not only will we share best practices, but we will also embed care managers in select partner sites.”
- Centralization – The participative, cross-organizational nature of DSRIP doesn’t lend itself to a fully centralized care management approach.
Why Hybrid? Clear advantages emerge for hybrid CMOs:
- Local solutions, best practice foundation: PPS’ are uniquely positioned to become learning laboratories capable of creating homegrown care management solutions, which are sustainable in their local medical neighborhood (i.e., the PPS as a factory that churns out care management solutions with the participation and buy-in of the community, but all built on a foundation of best practices in care management design).
- Navigating obstacles: Given their mandate and shared incentives, PPS-led CMOs can better eliminate traditional provider obstacles – “who should follow up with the patient?”, “why should I be involved in DSRIP?” and “why share data with competitors?”
- Outcomes buffer: If some partners are falling short of targets, the PPS has the ability to redeploy its highly trained team of care managers to better address hotspot ZIP codes or focus on a particular DSRIP project or help a challenged, high-volume ED.
What’s involved? Here is an abridged checklist for a CMO blueprint design:
Staffing – team composition, staffing ratios, job descriptions, accountability
Training – motivational interviewing, chronic conditions, etc.
Embedding – protocols for deploying care managers in model practices, ED/hospitals
Monitoring – performance appraisals, feedback, remedial actions, etc.
Handoffs – patient transfers protocols across settings, care managers, and organizations
Care Pathways – for chronic conditions like COPD, CHF, CAD, asthma, etc.
Policies & Procedures – for transitions, medication reconciliation, elder abuse, etc.
Workflows – screening intake, patient referrals, assessments, enrollment, interventions, follow-ups and case closure
Provider Engagement – educational sessions on care management, care team integration, etc.
PPS’ are uniquely positioned to fill a CMO void on a regional basis with their own locally crafted solution – will the majority of them capitalize on this opportunity to be successful within the 5-year DSRIP program and help set the rules of the game beyond DSRIP year 5?
For more information about DSRIP, contact Andrew Blackmon at email@example.com.