Health for life

In yesterday’s posting on care management nurse-staffing ratios and their associated costs, Peter McMenamin pointed out that a per member per month cost (PMPM) that ranged from $8 to $17 was a reasonable estimation.  Whats more, it compared favorably to the monthly management fee in the Comprehensive Primary Care Initiative. 

This is also important for Accountable Care Organizations that are grappling with the amounts that they’ll need to invest in care coordination to achieve the shared savings.  Assuming an ACO becomes accountable for 5,000 beneficiaries, that calculates out to between $480,000 and $1,020,000 per year.

But, asked the Disease Management Care Blog, should there be any differences in care management ratios and costs for Medicare, Medicaid and commercial insurance?  If it’s a commercial ACO, should it estimate $500K, while a Medicare ACO should plan lower ratios and invest $1M?

Peter McMenamin’s thoughts:

A parity between Medicare, commercial, and Medicaid is possible but not exactly plausible.  Thanks to many co-morbidities, Medicare patients have more different docs, more visits, and more drugs.  Unless they are particularly compliant with respect to medications, you’d expect Medicare patients to be more demanding.  Unless they return to a physician so frequently that care coordination is incidental or are hospitalized so much that their care is taken care of, they need considerable care management. If Medicare patients take more time for follow-up, etc. that might explain the difference between $20 PMPM and the somewhat lower PMPM estimates from my calculations.

Good point, of course.  Yet the DMCB is not so sure that there is a correlation between savings and the intensity of care management beyond a certain threshold for any patient of any age.  In addition, while persons with Medicare have greater illness burden, that doesn’t mean the day-to-day management, care plans and shared decision making for conditions like diabetes or heart failure making varies depending on a patient’s age.

Dr. McMenamin and the DMCB will keep their eye out for answers.  More to follow.

Its no secret that the Disease Management Care Blog is an enthusiastic believer in nurse care managers.  In its humble opinion, it makes no difference what "bricks" are used to build a Patient Centered Medical Home, an Accountable Care Organization, a Population Health Management Program or an employer-based care support/wellness initiative, the nurses are the mortar.

Readers can read more on how this specifically works in a DMCB co-authored article titled "The Focus of Case Management Grows" in this on-line version of The Case Management Society of Americas (CMSA) Case In Point magazine.

While the manuscript focuses on the PCMH, its lessons can be applied to any corner of primary care:

1. Some patients have higher health care needs, more care gaps and greater risk.  Surveys and analyzing insurance claims and electronic health record data can find them.

2. There are cheap medical  interventions that increase quality and lower costs.  Nurses know about them and, when theyre supported by physicians, can champion their use among patients with the most to gain.

3. Most patients want to meaningfully participate in their own care.  This goes to the core of patient centeredness and these nurses know how to harness that energy.

As systems confront the limitations of pay-for-performance, the disappointments of the EHR Kool-Aid, the inertia of Washington-run health care and dwindling budgets, the DMCB is confident that these nurses will finally get the recognition they deserve. Whats more, patients will be better off for it.

Well talk diabetes in a sec Mrs Smith, but first, hows those darling kids?

Just being back from a whirlwind tour, the Disease Management Care Blog is happy to report that it became newly acquanted with some colleagues who are furiously at work building care management programs for newly minted integrated health systems and ACO wannabes.

They provided two big insights for the DMCB:

1) While the DMCB guesstimated that the typical ratio of care management nurses to enrollees amongthe mainstream care management service companies was in the range of 1:1500, at least two new programs are using a 1:750 ratio.  By the way, 1:800 is what was quoted in this peer reviewed article.  Thats a lot of nurses for an "accountable" population and a lot of budget for a CFO to approve. 

2) There is less of an emphasis on care manager "productivity,"  thanks to a recognition that nurse-client conversations outside hard nosed chronic illness management "engagement," "barrier identification" and "shared decision making" contribute to relationship building.  The DMCB thinks of this as "magic nursing dust" that adds to the likelihood of patient behavior change.  There are no hard data on the topic, but its important in other parts of the health care universe, so why not here?