Moving Toward Meaningful Integration

Rob Pock
Founder and CEO
TCS Healthcare Technologies

With all of the market forces at play and major reform efforts underway, both at the federal and state levels, it’s important to understand how these trends are impacting the practice of case management. Clearly, one trend is the need to promote and move to integrated "care" solutions. The move to enhanced clinical and administrative workflows often is dependent upon linking existing activities and interventions through emerging ideas, technologies, business platforms, and evidence-based clinical pathways. This column highlights some of the ongoing challenges and opportunities to promote a more seamless environment for case managers and the patients they support.

Delivery System Integration

The bi-furcation of the insurance function from the provider delivery system is common throughout the United States. Almost everyone agrees that the delivery and financing of patient care is fragmented, and attempts to better coordinate care often face legal, market and institutional barriers.

However, efforts are underway to figure out how to increase the payment, efficiency and connectivity of healthcare. The formation of accountable care organizations (ACOs) is one example of an emerging concept that is being discussed. ACOs are viewed as a mechanism to allow physicians, hospitals, case managers and other clinical caregivers to address some of the perceived delivery and coordination challenges in the current healthcare delivery model – while at the same time allowing clinicians to assume some of the financial and business risks associated with patient care. CMSA also has addressed the issue of fragmentation in some detail with its support of effective transitions of care (see March 2011 column).

Information Technology Integration

Healthcare system fragmentation also is perpetuated by information technology (TI) platforms. In most cases, IT systems need to improve interoperability and other data interfaces to optimize the ability to better serve providers, patients and payers. We addressed the need to connect disparate IT systems deployed in the U.S. healthcare system in a CMSA column published earlier this year (see January 2011 column). While much work still needs to be done in this area, there a few care management software systems that are fairly effective in integrating various sources of data in a way that case managers and others can act upon.

Consistent Regulation

Inconsistent regulation also can hurt the ability of case managers and others to work in an integrated and seamless manner. A microcosm of this tension is highlighted by efforts to implement the Patient Protection and Affordable Care Act (PPACA) as both the federal government and the states develop the exchange-based marketplace that will offer qualified health plans to individuals and the small groups. It will be interesting to see if the regulators implementing PPACA can establish a more level playing field than the current regulatory system, with a primary goal of preventing adverse risk selection from one insurance pool to the next. Another example is the over-lapping and sometimes inconsistent regulation covering utilization management, case management and external review activities.

Program Integration

Sometimes there is enough integration of the clinical, business and IT workflows to do something special with chronically-ill populations. Through an integrated and coordinated platform, case managers can do wonderful things as they identify, track, and improve targeted patients, who often suffer from a wide-range of co-morbidities and social problems. There are a number of care management organizations and health plans that have the right mixture of activities in place to do something special. In such cases, integrated care management programs often produce improved clinical and financial outcomes.

Meaningful Integration

Clearly, one size does not fit all. But the power of integration is becoming even more important in this ever-expanding world of complexity. Facebook links us virtually, cell phones and texting keep us connected no matter where we are, ATMs make accessing cash easy, and iTunes makes downloading music a snap. It is going to be exciting to see how case managers adapt and change in this technology-dependent age. Although we will have many "tech" challenges ahead, case managers (and their patients) should not fear change. Good things are going to happen. Integration must become a fundamental value.

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