High risk case management will save mega dollars?
Or will it
Im often asked “what does the evidence say” in this space. Fortunately people considerably cleverer than me have already answered.
See my other blog also – Ten reasons to be cautious https://gregfellpublichealth.wordpress.com/2016/09/08/case-management-key-workers-10-reasons-to-be-cautious/
Four pieces of evidence spring immediately to mind
1) Commonwealth Fund Models of Care for High-Need, High-Cost Patients: An Evidence Synthesis
This one is currently the State of the art evidence in this area
“Overall, the evidence of impact is modest and few of these models have been widely adopted in practice”
Exhibit 2. Summary of Evidence for Complex Care Management by Site and Modality of Care
Care models for high-need, high-cost patients offer the potential to achieve the “triple aim” by reducing costs while simultaneously improving patients’ health and care experiences. Few of the care models examined in this brief have demonstrated net cost savings, which suggests that our expectations should be modest when adding care management to an already fragmented fee-for-service care system. The incentives created by accountable care and other value-based purchasing initiatives may strengthen the business case for adopting carefully designed and well-executed models.26 Public and private purchasers must consider the adequacy of payment methods and performance measurements to ensure that savings ultimately accrue to society or consumers while also attracting sufficient participation among providers and improving outcomes for patients.27 “
2) Nuffield Trust Developing care for a changing population: Supporting patients with costly, complex needs
Section 4 has 10 reflections that about sum it üp
3) Martin Roland’s various articles also set out the context very very well indeed
Esp this one – http://www.bmj.com/content/345/bmj.e6017.long
We overestimate importance of freq flyers
- If you want to make difference at scale – focus on big numbers
- We ignore regression to mean
- And Supply induced demand
- We forget about variation due to chance
- We implement unevaluated interventions and interventions we know don’t work
His advice to us:=
- Don’t assume that reductions in admissions in a high risk group are due to your intervention Evaluate your intervention against changes in overall patterns of admission or using a control group
- Don’t assume there is a correct level of admission or referral – Clinical audit makes numbers meaningful and should be used to identify where there are problems in care
- Don’t assume that fewer admissions or referrals are necessarily better – Doctors with low rates of specialist use may be a danger to their patients, just as high referrers may be wasting resources. Use clinical audit to bring meaning to crude rates of referral or admission
- Be cautious about using data for short time periods or referrals to single specialties— Random fluctuations may account for much of the apparent variation in provider performance when numbers are small. Use table 22 to assess how much variation might be due to chance
- Choose interventions that are evidence based – Use information from reliable sources such as the Cochrane Effective Practice Group (http://epoc.cochrane.org),
- bear in mind that context is important. Carefully shaping the way an intervention is introduced may increase its effectiveness, and don’t forget that most changes can have unexpected consequences too.
4) Focusing on High-Cost Patients — The Key to Addressing High Costs? — NEJM
“In reducing wasteful health care utilization, patient-focused strategies targeting high-cost patients may be less effective than systems-focused strategies intended to reduce low-value services for everyone. But current incentives favor a focus on high-cost patients……
……..Thus, a focus on high-cost patients may not only fail to contain health care spending, it may help to entrench the status quo, since targeting specific patients suits existing provider structures developed under fee-for-service incentives”
Cost savings in ACO model. McWilliams. Mostly coming from population approach not high risk approach
- Such models are a good thing
- Certainly plenty of evidence in NHS context that key work / case management whatever we want to call it basically about washes its face financially speaking – yes reduction in utilisation but net cost neutral.
- That’s when focused on complex highest risk.
- It may be a case that case management would increase costs as previously unidentified needs are uncovered. This may improve outcomes, it will incur costs. This obviously offsets any monetised savings from improved outcomes
- I don’t doubt that keyworker / case manager sort of stuff is def one of the building blocks of population risk management.
- When focused in on lower risk – it’s probably a net cost
- Better quality, may be opportunity to turn model on head – same q of care to hospital and cheaper setting (that’s def the hospital at home paradigm …. See the various Cochrane reviews, esp step up review)
- Certainly not likely to save the mega dollars that everyone says it will…..sadly…
- I still remain to be convinced. It’s undoubtedly a good thing, but we shouldn’t have unrealistic expectations financially speaking
One productive way forward
Maybe instead of growing an army of key workers should we turn it round and build the expectation of key working into existing roles and competencies
So the job becomes one of defining those competencies, recruiting against them and building into expectations and SOP of our services
then the £resource we MIGHT have invested in key workers we invest in basic services instead.