Your team will work with the manager of the medical management department of a small integrated healthcare system, which includes several hospitals, a network of physicians and specialists, and outpatient clinics that have a high volume of Medicaid patients. The Chief Medical Officer (CMO) has asked the team to work with the manager to improve the organization’s medical management programs, such as disease management and case management intervention strategies, and track the outcomes and costs of care to help manage patients with chronic diseases, such as asthma and diabetes. Recent reports for the organization showed that avoidable emergency room and hospitalization costs for these patients have increased steadily over the last few years and that appropriate primary care and specialty care is underutilized for many of these patients.
The organization currently has case managers and a disease management program for some patients with chronic diseases. The case management and disease management program intervention strategies currently include patient assessment, care planning, patient and provider education, as well as monitoring utilization of health services, such as primary care and specialty office visits, lab tests and results, and prescriptions. Other interventions that have been useful in patient management are appointment and scheduling reminders, mailings of educational materials, and regular telephone conferences with patients and providers. Patient compliance with care plans and active participation of patients in case management and disease management programs are often challenging, because of lack of incentives, transportation, and other socioeconomic issues with many Medicaid patients. Many of these patients do not regularly see a primary care physician, and some patients on Medicaid do not have consistent and valid home addresses, email addresses, or home telephone numbers.
Information on medical management interventions and outcomes for patients are tracked manually, and opportunities to identify patients at-risk are missed due to lack of access to complete and timely information. Currently the case managers and disease managers have access to a basic disease registry in a database created by the Information Systems department. An electronic medical record system is currently only available in the hospitals, but not in the physician offices. The Information Systems department also provides a monthly report that lists those patients with chronic diseases who have been seen in the emergency room and who have been hospitalized. Also the finance department has some claims data from various providers, such as physician offices, hospitals, lab and pharmacies within the integrated healthcare system.
The manager has expressed a desire to develop or acquire a new system to track and manage the information and data that are available and identify any other useful sources of data to help manage patients with chronic diseases. The manager is also interested on how physician offices, hospitals, health plans, and pharmacies can also participate in this tracking system, in order to improve medical management strategies, communication, continuity of care, and reduce costs for these patients. The CMO agrees that the system needs to develop or purchase a new tracking system complete with performance indicators to help track progress toward goals and monitor the outcomes of patients with chronic diseases. The team will need to submit a proposal with recommendations for a new tracking system through the CMO to the rest of the integrated delivery system’s senior leadership team. These efforts will also help the organization comply with Pay-for-Performance programs between the health system and several health plans.
• Financial analyses, which will include, at a minimum, the revenue impact, cost reductions, capital budgeting (NPV and IRR, assuming a cost of capital of 10%)*