Healthcare News & Insights

How hospitals and ACOs can approach complex care management

Managing care for patients with chronic conditions has often been a struggle for healthcare providers. These high-need patients require consistent monitoring and often result in high expenses for healthcare providers with limited reimbursement. But that won’t be the case for much longer. 

495540655Beginning January 2015, Medicare will pay hospitals and other providers a monthly fee for complex chronic care coordination, according to a recent article in the New York Times.

Chronic care reimbursement

Specifically, the Centers for Medicare & Medicaid Services (CMS) will pay $42 a month for each patient treated with two or more chronic conditions. However, in order to be reimbursed for complex care management (CCM), certain criteria must be met.

For example, care management can only be delivered and reimbursed if patients have agreed, in writing, to pay about 20% of the cost. Since not all patients understand their financial obligations for CCM, it’s a good idea to explain it to them and find out if they’re willing and able to pay for their portion.

Physicians will also have to develop comprehensive care coordination plans for these patients and utilize electronic health record (EHR) systems to exchange information with other providers. Thankfully, CMS is allowing nurse, physician assistants and other nonphysician providers to administer care management services. The agency will expect physicians to focus their efforts on high-risk patients with four or more chronic conditions.

ACO approaches

Often, the challenging and expensive task of complex chronic care coordination falls on Accountable Care Organizations (ACOs).  These groups of healthcare providers and insurers must approach CCM strategically if they want to successfully deliver high-quality, cost-efficient care.

Recently, a group of researchers at the Commonwealth Fund released their findings on ACOs that have effectively implemented CCM, according to a Fierce HealthPayer report.

Specifically, the researchers looked at 18 ACO programs to see what methods and procedures resulted in the best CCM.

The best ACOs had these four key methods in common:

  1. Tailor to the local environment. Consider the size, location and governance of provider partners before joining up with them. Before you include a primary care physician in your ACO’s CCM efforts, evaluate the quality and efficiency of their care.
  2. Identify best patients. Your ACO should solicite feedback from patients with chronic conditions in order to understand what healthcare challenges they’re facing. Invite patients to help your ACO determine your CCM program’s desired outcomes and the best methods to address their chronic condition needs.
  3. Share information. ACOs should exchange cost and health information, as well as best practices among insurers and providers to ensure effective care coordination and develop solid working relationships.
  4. Incorporate technology to remotely monitor patient conditions, assess real-time data and boost patient engagement.

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