Welcome to our “Innovators Worth Watching” series, spotlighting interesting and potentially disruptive players across a spectrum of industries.
The United States spends $3.5 trillion on healthcare per year, of which 90% goes towards the care of patients with chronic and mental health conditions. In seeking to both improve care for the chronically ill and decrease care costs, programs like Care Management Plus are entering the healthcare scene.
Care Management Plus is a national primary care program for patients with multiple chronic conditions. It typically serves older patients, those with mental health as well as chronic conditions, and/or those requiring any number of social services. The program‘s key feature is the inclusion of care managers on a patient’s care team. Care managers are directly embedded into primary care practices, and are trained to provide education and empowerment for chronically ill patients. This includes improving patients’ ability to self-manage their conditions, and connecting patients to community services suited to their specific needs. As care managers have a small caseload, they are able to spend more time building relationships with patients.
Since its inception in 1995, the program has had the ambitious goal of improving care coordination and quality, and reducing costs and physician work burden. The program has grown from ten initial testing sites to being integrated into 420 practices nationwide (as of 2016). But is this method of providing care for the chronically ill disruptive to traditional primary care? We put Care Management Plus to the test.
1. Does it target people whose only alternative is to buy nothing at all (nonconsumers) or who are overserved by existing offerings in the market?
It depends. Patients in Care Management Plus need to be referred through their primary care practice, so they are already consuming medical care. However, the program targets people who have historically not received the level of support and daily care management that they need, since daily chronic care management is either rare or nonexistent in traditional primary care. Until joining the program, these patients tend to over-utilize medical services (like the emergency room) since their needs are not adequately met.
2. Is the offering not as good as existing offerings as judged by historical measures of performance?
No. While the program is embedded in primary care practices, care is not provided by a primary care provider. Rather, care managers are typically nurses and social workers. Training for care managers consists of one in-person training day followed by eight weeks of online coursework. The training is specifically designed to provide specialized coordinated care, though it is not as much as traditional medical providers receive in their years of medical study.
Further, care managers do not provide medical care as defined by traditional standards; that is to say, they do not provide clinical care. They provide education on health conditions and medication, connections to community resources, and self-management support for both patients and caregivers. Care is provided by less qualified practitioners, but it is the care that patients benefit from the most.
3. Is the innovation simpler to use, more convenient, or more affordable than existing offerings?
No. Care managers are embedded in existing primary care practices, making it no more, or less, simple or convenient to access the program. Depending on the patient and their capacity for managing their own care, the program’s focus on self management and low-cost (or no-cost) community resources could be simpler than trying to navigate a complicated medical system. However, it could also be more difficult as patients get used to an entirely new method of care.
4. Does the offering have a technology that enables it to improve and move upmarket?
Yes. Care Management Plus leverages the Integrated Care Coordination Information System (ICCIS), a Health Information Technology System that enables physician practices to create reminder lists, track patient activity, perform clinical assessments, easily view all information on a patient’s chronic conditions and treatments at once, and perform other critical tasks.
ICCIS works in conjunction with a number of different electronic health record systems, making the program easily scalable with minimal effort for a primary care practice.
5. Is the technology paired with an innovative business model that allows it to be sustainable?
Yes. The care managers receive salaries rather than a fee-for-service. Being salaried allows care managers to spend more time to form personal connections with program patients, while also helping to increase productivity for an existing fee-for-service care model.
In the initial pilot of the program, the enhanced provider productivity generated enough revenue to more than cover the cost of salary and training for the care managers. This shows that the model of paying care managers in the program is sustainable for practices integrating the program.
6. Are existing providers motivated to ignore the new innovation and not feel threatened by it at the outset?
No. Care managers do not provide “typical” medical care—rather they provide supplemental services that primary care providers cannot provide—so there is no explicit threat posed by the program. Yet, Care Management Plus’ model of integrating directly into primary care practices, and helping improve provider productivity, entices providers to pay attention to the program and integrate it into their own practices. Providers want this program to succeed; it improves outcomes for their patients while also making their lives easier.
So, is this program disruptive? There’s no doubt that Care Management Plus addresses an important need for both patients and providers; patients gain access to coordinated care management for chronic care needs, while providers gain more support and see a reduction in costs for caring for high-need patients. However, the program does not take patients away from primary care providers, since it exists as an add-on to existing practices. Rather, it enables providers to better provide care as they always have, making it a sustaining innovation. Regardless, Care Management Plus is still an innovator worth watching.
