Change is in the air this year, and it is moving the focus more toward case management work in care coordination and value-based care.

  • The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule for the Medicare Shared Savings Program, called Pathways to Success, to emphasize care coordination.
  • One goal is to help people maintain better health and avoid ED visits and preventable hospitalizations.
  • CMS wants more focus on value-based care and less focus on fee-for-service care.

The healthcare industry in 2019 is experiencing accelerating change, particularly as it relates to care coordination and the shift to value-based care. Trends that took root about a decade ago are growing, creating more opportunities for case managers.

The Centers for Medicare & Medicaid Services (CMS) is moving the industry further in that direction by issuing a final rule for the Medicare Shared Savings Program. Called Pathways to Success, the rule was finalized on Dec. 21, 2018. (More information on Pathways to Success is available at: https://go.cms.gov/2UVtn7p.)

CMS issued the rule that formed Pathways to Success after seeing positive outcomes from the work of accountable care organizations (ACOs), says Rebecca Perez, BSN, RN, CCM, director of product development for Fraser Imagineers and the Case Management Society of America (CMSA). She also is the executive director of the CMSA Foundation.

The point of ACOs is to reduce ED visits and returns to the hospital. ACOs want patients to use primary care services instead, she says.

Many of these patients would remain healthy if they regularly visited primary care providers and focused on maintaining their health instead of only seeing doctors when they have problems that require an ED visit, she says.

CMS and other healthcare payers are beginning to recognize that one way to improve healthcare costs is to build on the current cultural trend of consumerism — the Netflix model, Perez notes.

When people are offered a better choice, more convenient services, they will steer toward those — like people switched from rental stores to Netflix.

“Rather than the patriarchy model of healthcare dictating what you have to do, it’s a move toward a model of the patient telling us what they want to do,” she says.

The idea is to offer patients more choices, which improves their healthcare engagement because they feel they are in control of their own health.

“If people feel in better control, there is shared decision-making and they are more likely to make better decisions,” Perez says.

This is where ACOs and Solutions for Success come in. ACOs can be more flexible and creative, which could enhance patient engagement. Some ACOs have been remarkably successful. The better outcomes are related to the ACO being a less bureaucratic, physician-led organization that hires case managers, she notes.

“The original plan was that the sharing of cost savings would be implemented over a longer period of time, but CMS saw that smaller ACOs led by physicians were achieving better outcomes than big, hospital-led ACOs,” Perez says. “The little guys were doing better than the big guys, and that pushed CMS to tighten the timeline that ACOs have to start taking risk in order to share in cost savings.”

Health systems have become involved with accountable care organizations because they need to, but they are conflicted about the model, says Gary Pritts, president of Eagle Consulting Partners in Cleveland.

“What I mean is the biggest hospitals receive the biggest chunk of healthcare funding; they’re the beneficiaries,” he says.

The ACO model provides financial rewards for reducing costs and increasing quality, but the financial incentives are less tangible for hospitals, which under the ACO model have to work more to receive less money, he explains.

“If Medicare ever goes to full capitation, hospitals will know better how to do it and have systems in place because they’re learning how to do it now,” Pritts adds.

But hospitals don’t want to move to ACOs too quickly because they’ll lose funds, he says.

For physician-owned ACOs, there is less conflict. They save the ACO money by keeping patients out of the ED and hospital, and they share in those savings. “Physician-led ACOs are the ones that are able to push the envelope and get significantly more cost savings and better results,” Pritts says.

Some physician-led ACOs are embedding case managers in hospitals and partnering with hospital case managers to improve collaboration. Others are contracting with case management providers or focusing on team-based, interdisciplinary models for care, Perez says.

These trends will continue with Medicare’s Pathways to Success, which was established to set value goals for ACOs, including accountability, competition, engagement, integrity, and quality.

“It is my understanding that the incentive to do this is reimbursement,” Perez says. “CMS is looking for everybody to move away from the fee-for-service model and move to a value-based payment model.”

CMS is not forcing this shift but is providing incentives to move in the value-based care direction, she adds.

Organizations following the pathways will need to improve care coordination and focus on creating a safer and higher-quality journey for patients and caregivers, says Cheri Lattimer, RN, BSN, executive director of the National Transitions of Care Coalition in Prescott, AZ.

“I see the same focus I’ve seen for the last five to 10 years, using a collaborative care team focus with patients and family caregivers,” Lattimer says. “This includes using professional case managers to assist and support the family and family caregiver, involving them in shared decision-making, understanding their expectations and priorities.”

ACOs, bundled payment models, and Medicare have helped spread case management services.

Health system ACOs are good practice for a future in which Medicare might operate fully in a capitated environment, Pritts says.

“The introduction of ACOs and CMS’ move toward value-based care brings the case management concept to greater use,” he adds. “ACOs are the one place where case managers are part of the whole strategy.”

Independent payers followed CMS’ lead, also driving the industry toward more case management, Pritts says.

For example, CMS’ Pathways to Success allows physicians and practitioners in ACOs to expand use of telehealth and provide patient beneficiaries with financial incentives to maintain good health.

The CMS 2019 Physician Fee Schedule Proposed Rule also includes changes that will fuel a drive toward case management, including policies related to telehealth and remote monitoring. (More information is available at: http://bit.ly/2N2hzh9.)

“There is a new reimbursement for remote patient monitoring, a Medicare-reimbursed service for patients with chronic conditions,” Pritts says. “This includes blood pressure monitoring, glucose monitoring, and weight monitoring.”

For example, patients can use an electronic scale that sends their weight to the physician’s office daily.

“This new reimbursement that is available permits care management, and the question is who will do that care management,” Pritts adds.

The traditional role of case managers also is needed as so much of the hard work involved in keeping patients healthy and adherent to their treatment involves optimal care transition and coordination, communication and education, and psychosocial supports.

Simply giving patients written discharge instructions will not accomplish the goals, Lattimer says.

“We need quality transitions, and to do that we need good communication between the patient, family caregiver, and patient care team,” Lattimer says. (See strategies to improve care transitions in this issue.)

The Medicare Pathways to Success offers significant opportunities for case managers, Perez says.

“These rulings create a lot of flexibility in improving performance for ACOs, and the requirements actually encourage them to innovate and expand access to higher quality services that are more convenient for patients,” she says. “For example, telehealth: I think we’ll see significant increases in the use of telehealth because it can keep people in their homes.”

Someone will need to monitor telehealth services and provide patient engagement, she notes.

“The Pathways to Success also allows health organizations to offer patients incentives to do preventive care,” Perez says. “These could be monetary incentives to get your colonoscopy or mammogram. These could be vouchers or a gas card.”

As long as a provider can show that the voucher connects to the patient receiving the necessary healthcare services, they are allowed. “It’s all about bringing people back to primary care and getting necessary follow-up care,” Perez says.