Case Management/ Care Management/ Population Health/ Accountable Care: Why are we so confused?

This blog is in reply to a question posted by Victoria Ng in LinkedIn’s Population Health Management, Accountable Care Organizations, Healthcare Data Analytics, PCM/ACO group. Victoria’s question is:

“Why do some ACO’s choose to implement care management technology while others don't?”

(Victoria is a graduate student at Columbia University and an intern at a tech company that is currently building care management technology). We’ll tackle her other question “How do ACO’s go about choosing which specific solutions to adopt” at a later time.

I have read countless articles, blogs and the like over the past 6 months asking these related questions: “What is Population Health?” “What do Population Health and ACO’s have in common?” “How does one select a Population Health vendor?” “What is Care Management vs. Case Management vs. Population Health?”

I have to admit, I get confused by all of these questions myself. These are not entirely new concepts. Similar care models have existed in one shape or form for as long as I’ve been a nurse, two decades at least. If they've been around that long, why are they still widely unrecognized?

This has been top of mind the past few months so when I read Victoria’s question, I decided to help in the best way I know how. I'm going to tell a story. I’m going to share what I was taught about the history and evolution of Care Management back in nursing school in 1990, and again in graduate school in 1999. These definitions have been reinforced throughout my career.

A Definition

According to the Case Management Society of America (CMSA), which has been the formal professional organization representing Care Managers since 1983, care management is

“a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.”

Sound like the beginning of an accountable care paradigm? And this was back in 1983...

So what happened?

The year is 1920. Case Managers routinely provide care and contain healthcare costs by coordinating services mostly available in the public health sector. In the 1920s, the need to manage chronic illnesses in psychiatry and social work blossomed, followed by the rise of nurses to support these services in the 1930s, and making house calls became commonplace. By the end of WWII, many nurses worked as Case Managers to help coordinate the multiple services needed by wounded veterans as part of their rehabilitation. The role of the Case Manager continued to expanded into public and private schools, and services including school-based health and wellness programs, preventative health screenings, as well as helping with other important day-to-day needs of families and the community were added to their role in the care of the population. With the advancement of the role, Care/Case Management soon became a specialized type of nursing.

Things remained largely unchanged until the mid-1980's when double-digit inflation forced health insurers to focus on cost containment. Insurance companies began developing Case Management programs that were targeted at cost containment of the catastrophically injured and ill population, and the disease or condition specific definition of Case Management, and inherently the cost containment focus, was born. This was the first narrowing of the role that Case Mangers played in the health and well-being of community populations.

The second narrowing of the role and focus of the nursing speciality occurred as inpatient hospital costs spiraled and reimbursement and revenue continued to diminish during the 1990's. Hospitals reacted by creating acute care (hospital) based Case Management Programs whose primary focus was on decreasing Length of Stay (LOS), early discharges, and cost management. The utilization focus was so intense that some nurses, for the first time in their career, began reporting up the finance chain of command rather than nursing. In the hospital setting, it is still common in some parts of the country to find Case/Care Managers whose only experience as a nurse has been on utilization and cost containment, and who continue to report up the finance chain of command.

By the late 1990's the intense focus on decreasing utilization, and movement away from the quality of care and patient advocacy activities of the past, began causing significant disagreements between Care Management Organizations (most notably HMO's) and Care/Case Managers. In fact, the perception of HMO's and Case Management became so negative in the public eye at one point that I would not be surprised if some of the reason "care" management emerged as a term (as opposed to "case" management) was an attempt by the specialty to to distance themselves from the negative backlash of the Managed Care/HMO movement.

Ask an organization if they have Care/Case Managers and they may say "no," but the same organization when asked if they have Discharge Planners or Utilization Review nurses, will answer "yes." Case Management has morphed into many different types of roles, it's no wonder there is so much confusion out there. (Here's a great reference textbook that will teach you everything you always wanted to now about Case/Care Management).

For this reason, parts of the country not significantly impacted by the HMO/PPO movement, (click here for the latest 2015 State HMO Penetration Rates) and who are largely Fee-for-Service (FFS) markets, may not see value in the services Case/Care Managers provide; especially since "care coordination" just became a reimbursable "code"in the FFS world, and to many in that arena, is a completely foreign concept.

As we turn from transaction based health care to value-based healthcare, more and more organizations will realize the value that Care/Case Management provides, and that you really can't take on accountable care for populations without the specialized coordination, facilitation, advocacy and quality assurance functions provided by Care/Case Managers. I hope to see all Care/Case Management roles return to providing the full scope of services of the past. It would be better for patients, and I bet it would be better for nurses as well. (And put them back under the Nursing chain of command where they belong for Pete's sake).

All of this was to say organizations not looking to implement care management technology are possibly still largely Fee-for-Service and don't see the value of a comprehensive care management technology solution. Also, many in the market are feeling beat-up and discouraged by their EMR implementations; they spent millions of dollars and can't get meaningful data out. It's no wonder there is hesitancy about care management/population health software, there is generalized "pay a lot, get a little" fatigue in the market right now. Those new to ACO care models are also facing monemental changes in operations and culture (much bigger than that required for EMR implementaiton) and probalby realize they have much bigger fish to fry before looking for care management solutions.

The next wave of analytic/BI/Population Health/CM software implementations provides the opportunity to make significant improvements in patient care, quality and cost. Organizations that understand and appreciate what these tools have to offer are probably already hard at work on Data Governance, Data Quality, and exploring innovative ways to model, store, and harmonize their most precious natural resource, their data.

If you liked this post, please share it with colleagues who might benefit from a greater understanding of Care/Case Management and how these specialists enable Accountable Care and Popultion Health Programs.