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Digging Into My Modest Election-Year Proposal For Healthcare Reform: Part 2 — Pivoting To Care Management From Our Obsession With Utilization Management

This blog is one in a three-part series that digs into my modest proposal for healthcare reform published at this site on May 27, 2024. See that blog here to review my proposal thoroughly: .

Much of my proposal is taken from my book, The Healthcare Labyrinth, available at this site and through leading bookseller websites. It is available in print, ebook, and audiobook forms.

Pivoting to care management from our obsession with utilization management

In my “A Modest Election-Year Proposal For Healthcare Reform” blog on May 27, 2024, I stressed that the cornerstones of reform are three key tenets – driving affordable universal access, reforming price, and pivoting to care management (CM) from our obsession with utilization management (UM). This week I cover the need to rethink how we approach management of patients or members.

In the May 27, 2024, blog, I argue that America is obsessed with UM or prior authorization (PA), where gates are put up in front of certain services and only allowed if authorized beforehand by health plans. This certainly has a role in efficient healthcare, but it should not be the main focus.

Indeed, far more could be saved if America invested in wellness, prevention, and true CM.

In this model, health plans would do the following:

  • Seek to understand members’ risks. As we know, member risks can be divided between clinical and social determinant risk factors.
    • Quite simply, clinical risk would evaluate the overall health of the individual largely by examining the number of disease states/conditions and other healthcare events that a person has. We know that severity of disease states drive costs. Someone with a well-managed disease state may head a quality life and not drive a great deal of costs in the healthcare system. As the disease state progresses or becomes less controlled, costs can increase exponentially and outcomes degrade. Clinical risk models show this. Look no further than the spending of dual eligibles (those eligible for both Medicare and Medicaid) for proof as well. These folks tend to be highly complex both from a clinical and social standpoint. They represent 17% of Medicare beneficiaries and 14% of Medicaid enrollees but consume 33% of traditional Medicare spending and 32% of Medicaid spending.
    • On the social determinant front, studies also show that non-clinical socio-economic factors also contribute to costs and outcomes. In fact, various studies suggest that social determinant factors can predict 50% to 80% of overall healthcare costs. Things like food security, housing security, transportation, health literacy and more are important to understand and intervene in.
  • Invest in holistic care of members and engage them in a personal model of care or care plan depending on clinical and social need. While plans will argue they invest here, much of the investment is meant simply to drive Star and quality scores. The engagement is not rooted in fundamental care management engagement principles. A true care management paradigm shift would invest in both technology and care management staff to:
    • Create a population health program with sufficient investments. Actively track every member for social and clinical needs. Pursue health and wellness opportunities. Adequately staff care resources for case and disease management interventions.
  • Make major new investments in primary care and prevention. America is not alone in having a primary care shortage, but other developed nations have done a better job of focusing on primary care. More dollars are spent by other developed countries on primary care. Here in America, we have an over-investment in specialty care.
  • Engage continually with both member and providers.

A paradigm shift

Plans would need to invest in a huge paradigm shift. But it is not just health plans. The federal and state governments need to do more to prioritize primary care investments, from payment rates to medical education to physician shortages. Government programs, health plans, and employers need to do more to ensure the establishment of primary care or primary medical home connections.

It can work

Making the shift from UM to CM would take time and resources, but the benefits are huge on both the cost and quality front. As noted in the May 27, 2024 blog, America spends the most on healthcare in the developed world by far (35% to 97% more than developed countries and 80% greater than the Organization for Economic Cooperation and Development (OECD) average). Further, it has the worst outcomes by far. I am embarrassed to say we are an outlier on quality even against the lowest developed world performers.

Take some of these findings from the Commonwealth Fund and Peterson-KFF Health System Tracker, all of which I tie back to lack of investment in primary care, wellness, prevention, and care management:

  • U.S. life expectancy is three years lower than the OECD average.
  • Avoidable deaths per 100,000 population in the U.S. are 50% higher than the OECD average.
  • The U.S. has the highest rate of infant (32% higher than the OECD average) and maternal (143% higher than the OECD average) deaths within the OECD.
  • The U.S. obesity rate is nearly double the OECD average.
  • U.S. hospital admissions for congestive heart failure (114% higher) and diabetes (133% higher) are demonstrably greater than comparable countries.
  • Adults in the U.S. are the most likely to have multiple chronic conditions.
  • Both the number of practicing physicians and physician visits are 30% below the OECD average. To make matters worse, the U.S. has many more specialists than other developed nations.

The news is not all bad. For example we do better on breast and colorectal cancer screenings. Our hospital length of stay is lower. Certain hospital outcomes are better, although some are worse.

But the statistics above point to a fundamental failing in the area of primary care, prevention, and disease management. It is clear to me that our lack of focus here leads to considerable costs and our poor quality outcomes.

Sources and additional reading:

#healthcare #healthcarereform #primarycare #caremanagement #wellness #prevention #sdoh #socialdeterminants #healthplans #hospitals #providers

— Marc S. Ryan

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