Wednesday, November 26, 2008

Bounties for Patients or Divvying the Market: the Next Frontier of Collaboration for the Medical Home and Disease Management?

After decamping the Hollywood Florida DMAA Forum 08 Meeting, the Disease Management Care Blog considered several presentations that described referrals to disease management programs by either physicians or medical home programs.

Be still the DMCB beating heart, talk about a “win-win” arrangement.

Wyoming Medicaid calls it 'Pay for Participation.' While Wyoming doesn’t have any managed care (it’s all fee-for-service or FFS) they do have vendor supplied programs in wellness, disease management (DM) and case management. After a lot of physician office outreach and education (focused not on the docs but on the office nurses), Wyoming Medicaid launched a series of billing codes that prompted referral of patients to the DM vendor. The interesting thing is that theses codes were accompanied by an extra payment. Essentially, physicians were being paid using a system already in place to refer patients into these programs. Wyoming reasoned that the work of referral warranted compensation. The vendor? APS.

In the meantime, Pennsylvania Medicaid’s ACCESS Plus Program serves FFS patients outside of Philadelphia and Pittsburg with disease management programs. Physicians are paid anywhere from $30 to $60 for patient referrals, working with the disease management vendor or signing off on a care plan. The vendor? McKesson.

And up in Boston, Massachusetts Blue Cross Blue Shield (MA BCBS) had one large medical group in its network with its own exquisitely designed diabetes care program. It was apparent to MA BCBS that this program was a ‘high intensity’ intervention that seemed better suited for complex patients - versus patients that would benefit from a softer and gentler version of telephonic disease management ‘lite’ coaching (the DMCB’s characterization). The fix? Predictive modeling was used to identify patients that would benefit from the physicians’ program and those that would benefit from the lite program. The large medical group agreed to this arrangement and even agreed to vet the referrals and endorse/sign the patient recruitment letters. Referrals to disease management increased and referrals to the medical group’s diabetes care program increased. The vendor? Healthways.

What did the DMCB learn from this?

By having physicians review and sign off on the referrals, insurers and DM programs can feel much more confident that the patients actually have the condition (a claims analysis, even buttressed with predictive modeling remains disappointingly inaccurate) and are more likely to agree to being entered in the program. That’s called ‘less effort on wasted letters and phone calls’ attempting to recruit patients. That’s spelled ‘C-O-S-T S-A-V-I-N-G-S.’

Paying primary care physicians for the work of referring patients into disease management programs makes sense. They need to assess the suitability of the patients’ fit as well as review and sign the letters. That’s called effort and is how things are done in an unbundled FFS world. The only caveat is the appearance of opt-in programs providing kickbacks to providers. That’s spelled S-T-A-R-K and the DMCB advises C-A-U-T-I-O-N.

Meaningful amounts of cold hard cash (this is not time for cheapness; the amounts above rival what docs get from their core FFS business) signals disease management vendors and their managed care partners are demonstrating a credible willingness to bridge the physician-disease management divide. The only problem is that it looks like Medicaid or BCBS is paying. The DMCB advises the disease management organizations to associate their name with the payments - like ACCESS Plus. That’s called G-E-N-E-R-A-T-I-N-G G-O-O-D W-I-L-L .

As is their wont, the Bostonians have kicked things up a notch by going beyond the Ver. 1.0 referral arrangements described above. Instead of cold hard cash for each patient referral, MA BCBS and the unnamed physician group have segmented the population and aimed the right resources at the right people: Healthways gets the ‘low intensity’ patients while the docs get the ‘high intensity.’ Both benefit from increase referrals. S-M-A-R-T

The DMCB suggests this may serve as the initial terms of endearment between the Medical Home and Disease Management. Let the DM vendors/insurers a) PAY the physicians for referrals to their programs as part of the care coordination suite of services and/or b) WORK WITH the Medical Homes to divvy up the market for mutual benefit.

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