Monday, October 26, 2009

The Guerrilla Approach to the Care Management that Underlies the Patient Centered Medical Home

At a recent webinar, the Disease Management Care Blog was asked how a regional health insurer implement a medical home if its provider network a) is dominated by small physician practices and b) there are no State-wide multi-payer-provider initiatives underway.

The DMCB at your service.

When it looks at what's been written about the core elements of the patient centered medical home, one recurring theme is the role of non-physician professionals - typically registered nurses - providing face-to-face (as well as remote telephonic) care management. The ingredients of that care management include patient engagement in the mangement of their own illness, coordinating that management with the primary care physician, acting as a primary point of contact for other members of the health care team as well as outside consultants, helping the patient to extract maximum value from the insurance benefit and maintaining and documenting an ongoing care plan.

Therefore, the guerrilla approach to creating care management to is for the insurer to establish that nursing resource for themselves.

Based on what it's heard on the non-Medicaid 'street,' the DMCB assumes that would involve a retail cost of anywhere from $20 to $50 per enrolled patient per month. Assuming that's true, it would dedicate most of that cost to the nurses' salary and benefits but take a fraction and give it to the physicians in exchange for letting the nurses into the practice. The DMCB is no business person, but a back of the envelope calculation suggests that each nurses would have to carry from 150 to more than 200 patients to cover their salary and benefits. There's some additional cost including the use of a car and laptops. The DMCB thinks the nurses would need to be distributed geographically and serve a hub of primary care sites, starting with the clinics that serve a large proportion of the insurer's patients.

Readers are probably thinking about the likelihood of getting this kind of sticker shock past the Chief Financial Officer. Yes, it IS pretty low, but you have several options: 1) argue that you'll only enroll patients that are likely to have $20-$50 in reduced claims expense thanks to the care management nurses' interventions, 2) sell the increased premium expense to customers that want a 'medical home' in their network (and that Medicare Advantage will use a bonus mechanism to cover that cost), 3) extract that cost by reducing payments for other services or 4) recognize this is a cost of doing business in an environment that demands the medical home all with or without the option of hiring a richly paid consultant (hint from the DMCB spouse).

The DMCB suspects some physicians will simply refuse to let a nurse into their practice. Other physicians will demand to hire their own nurse in exchange for the option of collecting the entire fee of $20-$50 PMPM. Fine, says the DMCB, but it would want to see a care management job description connected to a live care manager and have the option of performing an audit of the care plans.

Last but not least, the DMCB understands there are other elements of a medical home such as decision support, an electronic record, creating policies, NCQA recognition and 'transforming' the primary care site. While those other elements bring additional value, the purpose of hiring the nurses is not to establish 'medical homes,' but to create the greatest value proposition of medical homes: nurse-led care management.

The secret sauce here is the background, skill set, attitude and personality of the nurses. They need to understand outpatient primary care, appreciate the importance of patient engagement, buy into the notion of bridging the primary care-insurer divide and be smiling and steely-nerved ambassadors.

By the way, yes, that's a picture of Flo Nightingale above after her return from the Crimean front. Take away the bullets, and the DMCB sees many similarities between her role then and the new role demanded of nurses in the battle against chronic illness.


Leilani said...

Thank you Dr Sidorov for this well written post. As a disease management nurse, I can identify the points that you have raised in this article. I have the first hand experience from doctors refusing to partner with me to help their patients with chronic medical issues. The company that I work for contracts with an employer group who does not even inform their patient population that a disease manager exists. At most times, I feel like a miner buried in an avalanche of which there is no way out. I have gained several insights from reading your blog and although it is an uphill climb for my current job, it is rewarded by some patient who is able to show some improvement be it behavioral or clinical. Keep up the this great blog.

Jaan Sidorov said...

Thanks Leilani. You're right, a lot of docs don't get it and the purchasers don't support it. I personally think this involves a multi-year effort, usually involving one patient at a time. The good news is that history is on your side. Keep mining away, daylight ahead.

Leilani said...

Thank you Doctor. It is indeed a daily balancing act to be a disease manager. We all have to balance the following balls in mid-air - insurers who expect you to be miracle workers magically transforming ROI, patients who are difficult to engage and PCP's who don't buy the concept. We don't dare drop any of these balls to the ground. You are spot on when you said there are many similarities between her(Florence Nightingale) role then and the new role demanded of nurses in the battle against chronic illness.

Jaan Sidorov said...

My direct email is jaansATaolDOTcom