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Plan-Provider Collaboration on Care Management

Our quick take

Providers that want to own case management typically don’t have all the necessary capabilities and processes in place to effectively do so—their staffing models, infrastructure, IT capability, and organizational buy-in often fails to meet plan expectations. Plans, on the other hand, fail to streamline the data they give to providers into digestible insights and don't always offer meaningful and punctual provider incentives to encourage care coordination and outcomes-based interactions. These challenges make it difficult for CMOs to evaluate and engage willing and capable provider partners for case management delivery.

CMO commentary

It’s much easier to delegate to providers that are at risk because they have skin in the game so they feel the pressure to change their behaviors.

Providers often overestimate their capabilities and beg the plan to resume responsibility.

Providers are being us to hold them accountable for metrics they can control - there's a desire for increased standardization and alignment amongst plans.

Are providers better suited for delivering case management?

Three challenges plans face when delegating case management to providers

  1. Plans label providers who don’t immediately meet requirements to own care management as “risky
    Case study: L.A. Care lists specific next steps and deadlines for providers to participate in their CM program.

  2. Plans ineffectively share crucial data that providers need but can’t currently access without plan help
    Case study: Western Health visually shows “gaps” in refills and medication adherence on provider data reports.

  3. Plans incent providers on volume, rather than quality, of care management interactions
    Case study: BCBS SC added creative, bonus metrics (e.g., extended office hours) to provider CM incentives.

To learn more about case management delegation challenges, download the August Virtual Roundtable Highlights.

To learn about potential solutions, download the November Virtual Roundtable slides.

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