6 barriers to successful complex care management

Many healthcare observers are showing increased support for the implementation of complex care management teams as an effective means for reducing the cost of care to the small proportion of patients with chronic, complex diseases, according to a recent article published in The New England Journal of Medicine. However, there are several existing financial and nonfinancial barriers that prevent the widespread adoption of CCM.

According to The New England Journal of Medicine, the following six barriers most significantly impede the adoption of CCM:

1. The fee-for-service payment system. According to the article, the fee-for-service payment system is the most significant obstacle to CCM adoption for two primary reasons. First, CCM services are not easily separated into discrete units, and even when they are, these disaggregate CCM services are usually not reimbursed. Second, when CCM is affiliated with hospitals, the decreased rate of hospitalization due to effective CCM creates a financial disincentive for providers.

More preferable reimbursement models for CCM include those that reward the reduction of avoidable healthcare use, such as global payment or shared savings. Additionally, reimbursement contracts that hold providers accountable for the costs of care or hybrid models that combine incremental payments with fee-for-service systems can support CCM, the article states.

2. A lack of capital for CCM start-up costs. The cost associated with introducing CCM, including the cost of information technology and staff training, combined with unrealistic expectations for a return on investment in less than three years, contributes to stifled efforts to adopt CCM.

According to the article, start-up costs can be augmented through one-time supplemental payments. Contracts should also be for a more appropriate duration (around 3-5 years) to allow providers to implement the CCM program as well as make the required amendments to achieve a return on investment.

3. A lack of collaboration among managers and providers. Citing a Commonwealth Fund brief, the article states CCM is most successful when care managers collaborate with providers for their patients' care. While integrated delivery systems stand to accommodate close collaboration, most primary care is still provided by small or medium-sized practices that commonly operate independently. As a result, many of these do not have adequate resources or volume of patients to warrant hiring CCM staff.

The article suggests offering incentives to encourage providers to share resources to help practices achieve economies of scale and lower costs. Some of these include sharing patient registries, CCM staff, health information technology platforms and analysts to support quality-improvement efforts.

4. Lack of CCM expertise within organizations. The lack of experience and comprehension relating to the development and implementation of CCM programs is another substantial obstacle, according to the NEJM article. While the number of CCM training programs is increasing, high-quality, standardized CCM training is not yet widely available.

Educational institutions and other training and technical support organizations should make the development of CCM training programs a priority, and also train healthcare teams to collaborate effectively with CCM teams.

5. Underdeveloped analytics and HIT. The analytic approaches and HIT required for implementing CCM are underdeveloped, according to the article. Optimal analytics will offer opportunities to identify patients whose care will reduce costs with CCM, while health information exchanges could provide real-time information to CCM teams. Technology for population management and care manager workflow could also be improved.

Adoption could be accelerated through investing in the development of these technologies, as well as improving the integration of already available products into comprehensive EHRs.

6. Little evidence on net savings for CCM. The widespread implementation of successful CCM programs is an integral factor in a national cost-containment and quality-improvement strategy. Additional evidence regarding net savings would be a compelling force behind adoption of CCM; however, best practices still need to be developed for improving care for patients with complex conditions for various components of CCM.

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