Designing Prospective Care Management Models for Optimal Patient Outcomes

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Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I am your host, Daniel Marino. When you think about population health an important element in in really driving the outcomes of a population or really delivering the care that patients need care. Management is such a critical element. The right level of care management not only helps support physicians, and, as we know, physicians are over tax these days, we have to determine ways to to make it easier and more efficient for them. But care management also helps us deliver the outcomes that are absolutely critical to value based contracts. The challenge of care. Managers have, like with physicians as well in their office is understanding really where to start, how to focus on delivering the right care that the patients need, and understanding how to really support the patients and the physicians and delivering that right level of care most of the time. Care managers, as we think about care, the care management program focus on what I would call more retrospective or reactive care management. And what I mean by that is, they sort of respond to, Let's say what's written in the chart, or they respond to what's occurring with the patients and not really thinking proactively around what potentially the patients need ideally to really improve their care or deliver the best possible outcomes. So this this concept of prospective care management is really gaining a lot of attention, especially as we start to work with organizations, or, as we see, organizations taking on more full risk, global risk contracts. 

Well, I'm excited today to have 2 extremely knowledgeable guests talk about this concept of prospective care management. Our first guest is Dr. Ria Chatham. She's a national expert in population. Health has over 25 years of experience as a physician researcher and  a national medical director. She's done a lot of research around outcomes, cost of care models incorporating that into the right elements to drive efficient population health. My  second guess, as well as Kevin. Zo, he's Co. Founder, and CEO of care at health care at health is a platform that is really looking at a lot of different data, and artificial intelligence to drive new care models and new care management. Dr. Ria. Kevin. Welcome to the program. 

Thank you, Dan.

Kevin Zhao:

Thank you for having us appreciate it.

Daniel J. Marino:

So, Dr. Riya, maybe we could start with you. Given your experience, and you know you certainly have had a lot over your over your career. What do you see are some of the key challenges in the traditional care management structure that that we often see today?

Dr Riya Pulicharam:

Yes. So you know. there are lots of challenges in the care management processes and structure today.  it hasn't. I mean, it was still the same when I first started 25 years ago. It hasn't changed much over the years. One of the main challenges, Dan is It's more metrics driven, not outcomes driven. When I say metrics, it's important. Metrics is important, because that's how they measured right the care managers. So I'm not saying it should not be metrics driven, but it has to be equally and more outcomes driven. It also depends on the organization right? Some organizations are more metrics driven, and some organizations are shooting for outcomes driven as well. But where do we stop?  

Daniel J. Marino:

Let me dive into that for a second, because I, you bring up a really interesting point. So when we think about diabetes and it, let's say you have a patient who's a high risk diabetic. And we have let's say a metric to measure their level and high risk. Let's say we consider it. You know they have a 7.5, for instance. So I think what you're saying is oftentimes care management is really building the interventions around that metrics is 7.5. Instead of thinking about what are the care management solutions that would, that would almost drive the outcomes of reducing the high risk diabetic to maybe 6.9, if you will? 

Dr Riya Pulicharam:

Daniel J. Marino:

So it's really the outcome of of what the care managers are doing that needs to be that needs to be tracked.

Dr Riya Pulicharam:

Yeah, what is the result? Right? So of course, when I'm the manager leading a team of care managers, I do want to set the metrics, because I can measure how many calls they had to make. But at the end of the day it is also the outcomes of their calls. 

Daniel J. Marino:

Well, it's the it's the efficiency absolutely. So, Kevin, let me turn to you for a second. Historically, it's been very difficult to measure the, let's say, the productivity of care managers, and I think especially to to track it. How Dr. Riya is describing, thinking about not only what they're doing. But but what's the what are they producing out of the work that that they are creating within the care management platform? What's some of the data that you begin to look at, to really to drive that level of outcome? 

Kevin Zhoa:

Yeah, II think, there are a lot of existing point solutions today. That track, I guess the metrics set Dr. Riya is talking about. So how many calls you made, how many minutes you spent, etc. And these platforms tend to do well in more of a fee for service type of environment where the goal is to rack up, you know, I think, generally as many transactions as possible in bill insurance within the value based care space, which is where I focus on these types of your transactional tracking methods work less well, and what we have to do then, is figure out ways to translate some of these, you know, transactional tracking methods into more of these outcomes, you know, based, you know, assessments. One way to do this, for example, is, let's say, if you have an entire population of patients. You wanna be able to identify, you know, one for each, you know, cohort of patients. What's their likelihood of receptionist? The various, you know interventions or outreach, you know. If you reach out to a patient, for example. How likely is that patient to actually follow through with what you're asking them? The patient to do.  

The second is for example, you know the amount of effort. You know that each intervention, outreach or task is. Gonna take. So, for example, if you want a patient to, let's say complete a colonoscopy, for example, or you'll probably get a test done. You know. How much effort is it? Gonna take to reach out the patient, set those appointments and follow up with them? And then the last one is the actual outcomes ROI of that you know, task, or that this this intervention effort. So if a patient does go through with their call, mastery, mammogram, or etc., you know. What's that, Roi for you as a as a die based organization. And I think measuring the overall effectiveness. Productivity is a factor that you know it's a form that you have to multiply all these together, you know, in terms of knowing that your team, you know, has very limited resources. Let's say, of a thousand tasks like outstanding gaps you'll only be able to handle, let's say 100, you know, per week, or 100 per month, or whatever the the bandwidth is, how do you make sure that the highest ROI, you know overall tasks are done. 

Daniel J. Marino:

And that's a great point, because I'll tell you many CFOs, they understand what the costs are of the nesting in care management. What is difficult to track is the ROI. And that's right. And and I think if you're gonna start with that. Dr. Riya, it seems to me as Kevin was talking about it and describing, you know, those 3 elements. the care pathway. The care protocol, the clinical pathway care protocols that are put in place are critical, right? I mean, I think that's the source of truth.

Dr. Riya Pulicharam

Yes, so carepat is, you know, very important. As they assist us in clinical decision making right? And they also provide a recommended course of action, as these patients. Unfortunately, especially the most you know, expensive patients, right? The high-risk patients. They don't come with just one Comorbid condition. They come with multiple chronic conditions. And when you have multiple chronic conditions, you really need to balance. And you also need to. You know, coordinate this care pathway with social, determinant issues. So if they are tied together, then it becomes a really good protocol, and if that is not automated, then it's very difficult by any care manager. If their data resides, you know, in a siloed manner, in excel spreadsheets. And it's not. It's not all tied in appropriately. Then what happens? Is there? Is, there are these blind spots. You're not aware of something. You forget some things, and at the end of the day it just becomes more complex and more confusing. And then you don't get to the right data. So care pathways are only as good as how you position them, and how you automate them, and how accessible it is for you on every patient. 

Daniel J. Marino:

Dr. Riya Pulicharam

Daniel J. Marino:

Well and to your point, you're never going to truly achieve the outcome that you need to achieve for that particular patient. Because you're just relying on the task.

Dr Riya Pulicharam:

Yeah. And if you don't have a technology. See? I will tell you we are the last industry to get into technology because we, as physicians, nurses and health care professionals. We care about our patients. We work very, very hard and at the same time to give a lot of, you know, time to helping integrate technology. We used to see it as a waste of time. But now, after the pandemic, we've realized that we cannot scale without it. So the realization has come. It's also now the leaders who lead these organizations, they need to also be updated and educated. So we as healthcare professionals need more education on what's out there, there's a lot of information and lot of innovation happening. But we need that education. 

Daniel J. Marino:

I couldn't agree with you more. If you're just tuning in. I'm Daniel Moreno, and you're listening to value based care insights. I'm here today talking with Dr. Riya Pulicharam, and then Kevin Zao, and having a fascinating discussion around prospective care management. Kevin, I'm gonna turn to you building off of a little bit of what Dr. Riya had said the technology, the data is critical, right in providing that level of support to the care managers. How does technology? And maybe it's more around artificial intelligence. How does that come into play to really support efficiency in in care management support? Really the tools that the care managers need in order to drive the right level of outcomes.

Kevin Zhao:

Yeah, that's a good question. I think, to really assess that it'd be good to take a really quick step back and look at the existing environment, and I can break it down to to 3 sections, so to speak. The first section is your existing care management solutions which, from my observations, are mostly, you know, inpatients, you know, optimized for hospital administration, really optimized to rack up transactions, you know, really good in fee for service environments. That's kind of the status quo for care management solutions. Then, within the remote value based care, most value based care products. Are primarily, you know, data warehouses, you know, very high level that can, you know, ingest data for all your population and automate queries and identify lists? You know, patients who maybe aren't meeting certain metrics. And then, lastly, you have your your point solutions, your let's say you know, diabetes based solutions, you know, or your CHF, based solutions or digital health solutions, etc., which, you know, have pretty narrow focus. And you know, have a hard time really integrating with the, you know, overall objectives you're trying to hit from a value based care, perspective. 

Daniel J. Marino:

So about the technology in your experience. And obviously, you're doing a lot of work with different platforms and have a lot of experience in this area? In, in your, in your experience, are the tech, Now are the care management platforms that are out there today? Are they able to drive that level of of output that we need looking at all of the right, all of these data elements that you've described? Or is this, you know, continuing continuous new evolving technology?

Kevin Zhao:

  I think it's probably the latter. A lot of the really big existing solutions. Again, from my point of view, you know, are optimized for the old model of healthcare which is racking up as many transactions as possible. Billing reimbursement codes, etc., operating within, you know, inpatients, you know hospital environments, and I think the next wave of technologies really fits your prospective model, which is, you can, you know, reach the patients before they end up in the hospital or ER primarily using more outpatient based methods, etc., and focused more on outcomes. You know, how do you optimize kind of the workflows to get outcomes and not just, you know, kind of, you know, focus on cracking as many calls or visits, or, you know, kind of touch points as possible, you know, because those, while maybe correlated with outcomes aren't the outcomes themselves. 

Daniel J. Marino:

Well, and that's really where we need to go. You know, we we do quite a bit of work with organizations on helping them to what I kind of call the journey to risk right? Think about all of their the infrastructure that they need in order to efficiently engage and be successful in a risk-based contract. Moving to prospective care management and understanding the data and the modeling becomes absolutely critical. But you have to have the technology to do it without the technology. You're never, gonna you're never gonna achieve those efficiency outcomes. And I think, Dr. Riya, that's really your point. So 

just building off of what? What? Kevin said. Obviously to move into more prospective care management. It's critical right to the outcomes it's to to achieving the performance of the contract, especially as organizations are moving into, you know, risk based contracts, global risk contracts. How much of this prospective care management, approach. How much of this relies on the culture change that's required with our care management staff with our nurses, with our navigators. Is this a big culture change for them to think more prospectively? Or is this an easy transition for them? 

Dr Riya Pulicharam:

Yes, so you know, it's it's tricky. because. as healthcare professionals, we all understand the importance of outcomes. And I think we all come to the table with that aspect. But I think the design of the systems are flawed the way you know. Every organization is thinking about their priorities. Right? So traditionally, it's and continues to be to some to a large extent, is reimbursement. What have you done? So it's always those kind of tasks that have you completed your tasks. So unless and until there is a really big shift, we talk about value-based care all the time. and I've been in an organization for many, many years where value to outcomes was priority because it was led by folks that believed in it so much. And today it continues to be the belief. But are we changing the systems, the payment models, everything has to go hand in hand. Right? Yes, for example, coordinating between medical and social issues. You know, it's done as a PRN when needed. Why aren't we thinking? When we look at certain Zip code, certain patient population? Let's take the time to analyze their need. What does the patient need we? We put a label, non compliant patients. Believe me, as human beings. When when we are struggling, we try to look for help. But if we are put on hold, or we are not given that oxygen tank when we really request it. When we are not given the food in real time, when we don't have the food, and we tell our care managers. But then they have to talk to social workers. Then they have to talk to somebody else. But they've completed their task. They've touched the patient. How do you think we can bring a lot of change culturally? Lot of change to organizations when organization has to put in that process. And I'll tell you, care managers are always understaffed. They believe I believe they're understaffed, you know why? Because not efficient systems don't support them. and I feel my heart goes out to care managers because they are overworked, but they overworked in an inefficient manner, because  they are set to fail. So what we have to say or we have to do, sorry is really think about rethinking care management. How do we rethink, give them the innovative solutions we ourselves, as leaders have to learn. What are those innovative solutions? Are those innovative solutions validated? Have they done a study to show that it's working, creating the right level of efficiencies and outcomes. Right? That's really where we need to go, then incorporate them and support and redesign some of that. And then also, the reimbursement has to tie into that redesign which is outcomes.  

Daniel J. Marino:

Yeah, absolutely. Well, I you know, I sort of bring it down to. And we talk about this all the time. The success comes down to people processing technology. But the process has to evolve. So you're thinking about delivering this care differently. Not just task oriented, but outcomes. Oriented, is, I think, to your point, and the technology needs to become more robust. Right? So it needs to incorporate all of that data and synthesized in such a way that it becomes more of a resource to our care managers. So then, with, under the people part of that equation. The care managers provide more success around their outcomes and then aligned to that incentive, I think, really is what it comes down to. 

Dr Riya Pulicharam:

Yes. 

Daniel J. Marino:

So, Kevin, let me let me ask a question, and real quick being that so much data now is figuring into the care of the patients. Right? It's not just the clinical data that's important. But you know, as Dr. Ria said, it's the social, determinant data, it's the lifestyle data. You know, there's financial data that comes in. It's so in understanding that obviously artificial intelligence is a way to help us understand and make sense of all of that data. How in your experience, does that fit into an optimal care management or prospective care management program? 

Kevin Zhao:

Yeah, it's a good question. I think, from a very high level it boils down to how do you optimize your workload for your care, managers with respect to outcomes? And to dive a little bit deeper. There's a few factors I think we could look at first is, as Dr. Riya mentioned, resource management. So if you know, for example, your maximum bandwidth is one medical assistant for 1,000 patients, and that's all you can afford. How do you actually create workflows? That's manageable, you know. Given you know those constraints. 

The second part is, you know, trying to be able to predict or identify patients who are already enrolled in your intervention programs based on the rate at which, let's say, you know, tasks are being performed, and patient response responsivity, you know, identify patients who are likely to, you know, really fail various, you know. Compliance measures, you know, 6 to 9 months in advance and be able to focus on these patients, you know, prospectively. So that's the second part. 

A third one really is. Figure out, you know, kind of, as I mentioned before, you know. Be able to assess the ROI of all the tasks being done by your staff with respect to these outcomes. So one component, again, is, you know, figuring out which across your entire patient population, identifying, you know, which patients are likely to be receptive to certain points of outreach which ones are not. And so, for example, if you have a thousand patients, and there's 150 of them that you know you could engage with them until you're blue in the face, and they won't do anything. It's probably not worth spending too much time on these patients, whereas for maybe these 300 patients over here, if you spend X amount of time, you know, they may actually give you y amount of engagement. You know, you may want to spend, you know, more time with these patients.  

Daniel J. Marino:

Well, Kevin, Dr. Riya, I wanna I wanna thank you for for coming on today. Daniel Marino: I think this is critical to the success of of many organizations, especially as they further move into value based care, and different levels of contracting and certainly assuming a level of risk within these contracts. Before we wrap up. If any of our listeners today are interested in connecting with you or learning a little bit more about some of the topics, some of the things that we discussed today. You know, Kevin, a. Any thoughts where they could drive into maybe your website or email or Linkedin, or anything in that regard.

Kevin Zhao:

Yeah, of course. So our company caret health really focuses on helping. You know, risk bearing entities create these turnkey programs, you know, focus on prospective care management. Our website is https://www.carethealth.com That's spelled CARET. health.com feel free to visit and learn request more information. We have videos. And you can also request a demo on our website as well.

Daniel J. Marino:

Great. Well, I appreciate that. And Dr. Riya, I especially appreciate you coming on today and providing a lot of your background and vast amount of experience you have on the national level. And certainly all the research that you've done within population health. As we talked about, I firmly believe this is critical to the success and and the future direction of value-based care. So thank you both for joining today.

Dr Riya Pulicharam:

Thank you, Dan. And I just wanna, you know. Thank you for the opportunity. But also yes, I'm continuing to do a lot of research work to progress. The practice of medicine also reduce the total cost of care, because, as you know, in the Us. We are number 32 in quality and number one in expense. 

Daniel J. Marino:

Yeah, absolutely. And that does need to change. You are absolutely right. Well, I wanna thank all of our listeners today for tuning in, and until our next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners