Providers increasingly are sharing with payers the financial risks associated with patient populations. Beyond specific treatments, this model requires them to focus on the entire continuum of care for their patients. As risk has shifted, providers have found that an effective way to manage risk is via care management programs that target patients who are likely to be high-volume users of healthcare services.

In a series of case studies published by the Commonwealth Fund in 2013, effective care management of chronic conditions such as asthma and heart failure and a program targeting a Medicare-Medicaid dual-eligible population resulted in significantly lower hospitalization rates. Average time between hospital encounters increased for those enrolled in the asthma program, while heart failure patients and dual-eligibles reduced 30-day hospital readmissions by 46 percent and 21 percent, respectively.a

Selecting Patients for Care Management

Successfully developing and utilizing care management programs requires providers to think both big and small. They must develop a sound population health strategy while also having effective care coordination and communication with patients on a one-to-one basis.

“When you start taking on risk or a shared-savings arrangement, you start to think about a population health strategy, and that requires a different set of tools,” says Vanessa Pratomo, MD, medical director for ACO quality improvement and chronic illness management at Montefiore Health System in the Bronx, N.Y. “It requires not just providing that direct clinical care, but also looking at the group of patients you are servicing and trying to understand who is at high risk—who do I think is going to be really sick?—so I can get ahead of that need and provide this person with the services that can keep them healthy.”

According to Clemens Hong, medical director of community health improvement at the Los Angeles County Department of Health Services, care management programs typically target a relatively small subset of a healthcare organization’s patient base: those with complex chronic conditions. These complex care management programs appear promising, but many have not shown definitive results.

“High-risk care management allows you to provide, in a very tailored way, high-quality care to a subset of your patients who have complex sets of needs,” Hong says. “You tend to see improved quality of care and improved experience for those individuals who are perhaps your sickest and most vulnerable. You may see reduced utilization of emergency departments and hospitals, but it’s harder to return the money you invest in the program.”

Although reported financial results appear mixed, Hong thinks “the problem often is not in the concept, but in how the concept was implemented.”

Common implementation errors include not adequately leveraging internal data and the claims data of payers in the organization’s network, and as a result not accurately identifying the cohort of patients most likely to be high-volume users of services. But Hong points out that selecting which patients to actively manage is not simply an exercise in data analytics.

The most effective programs, he notes, also consider qualitative approaches—information that physicians can provide based on their knowledge of individual patients. Such observations may include a patient’s temperament, his readiness for treatment, and his ability to follow treatment plan.

Hong thus recommends a hybrid approach to patient selection for care management, one that combines quantitative evaluation of patient data with qualitative information based on firsthand knowledge about patients from their primary care provider.

“Data is critically important, but it doesn't provide you with all the information you need,” Hong says. “Once you have generated a list from the data, you put those lists of patients in front of the doctors and ask them to choose, based on the structure of the program and their knowledge of the patients, which ones they think are most likely to benefit.”

Overcoming Barriers

A major challenge to implementing care management is the deep-rooted influence of fee-for-service at all levels of health care. “If you think about the average physician, a patient is scheduled, then comes to see you,” says David Wennberg, MD, former CEO of Northern New England Accountable Care Collaborative and currently chief science officer at Quartet Health, a New York-based startup that uses advanced analytics and clinically guided technology to improve the integration of behavioral and physical health care. “What providers don’t have is proactive population approaches to managing patients at risk. One reason is they are accustomed to transactional activity only.  My advice is that they should be as concerned about the patients they aren’t seeing as those who are in their office.”

Michael Hunt, DO, interim president and CEO of St. Vincent’s Health Partners, the first URAC-accredited integrated health network in the country, says the Bridgeport, Conn.-based physician-hospital organization effectively codified this broader view of patient care by requiring physician practices participating in the network to be certified as patient-centered medical homes.

“Our strength is that we designed our model to enhance and support the physician who takes care of the patient,” Hunt says. “We put the focus on the primary care provider, so they can be the captain of the therapeutic plan for their patients.”

To ensure the primary care physicians stay informed and engaged in managing the health of their patient panels, St. Vincent’s care coordinators have a clinical background and meet at least monthly with the physicians and care teams. The purpose of these meetings is to present actionable data on patients while also building trust.

“It is a collaborative relationship between the care coordinators and the providers,” Hunt says. “We expect them over time to get to the point where the physicians and their office staff view our coordinators as a part of their care team.”

Although St. Vincent’s spends considerable resources to keep primary care physicians informed and engaged, the physicians are expected to play a central role in managing the health of their patient populations. This philosophy includes a care management model that comprises all the tenets of a patient-centered medical home. “We are asking them to be responsible for patients in a way they have never been held responsible,” Hunt says. “When the patient is discharged from the hospital, the hospital team 'owns' that patient until the patient is in bed at the skilled nursing facility. When the patient moves back home or back to the hospital, they own that patient until they move to the next level of care.”

Gaining access to information on all the care that patients receive is a significant benefit of care management. As Wennberg notes, even in smaller markets in the Northeast that feature a single, dominant health network, between 25 percent and 50 percent of care is delivered outside the network. So developing data systems and processes and having access to payers’ claims data—then providing the relevant data to care teams—enhances the quality of care delivered and reduces overutilization of services.

“If you think of it from a risk standpoint, which is moving away from a transactional payment to some kind of performance-based payment, having people not go immediately to the emergency room or not self-referring to specialists is really important,” Wennberg says. “And while a primary care provider can help encourage that, it is my opinion that they can’t do that alone. They need true team-based care to do that, and part of that team is the care management component.”

Chris Anderson is a freelance writer and editor who covers payers, new care models, healthcare IT, and precision medicine.

Interviewed for this article: Vanessa Pratomo, MD, medical director for ACO quality improvement and chronic illness management, Montefiore Health System, Bronx, N.Y.; Clemens Hong, medical director, community health improvement, Los Angeles County Department of Health Services; David Wennberg, chief science officer, Quartet Health; Michael Hunt, DO, interim president and CEO, St. Vincent’s Health Partners, Bridgeport, Conn.


a. McCarthy, D., Cohen, A., and Bihrle Johnson, M., “Gaining Ground: Care Management Programs to Reduce Hospital Admissions and Readmissions Among Chronically Ill and Vulnerable Patients,” The Commonwealth Fund, January 2013.

Publication Date: Tuesday, February 16, 2016