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What is Clinical Care Management and Why is it Important?

Like fashion, healthcare trends come in and out of vogue through the years. Some trends never come back in style. Reputable trends, like Clinical Care Management (CCM), shift and change throughout the years. As healthcare spending continues to rise, with Peterson-KFF noting a 6.4% average growth over the last two years, CCM is again back in vogue. Is this cost management tool here to stay, or another passing fancy? How do you determine if it is a wise decision for your clients? It’s vital to understand what CCM is, the benefit of choosing it, and the characteristics to look for when considering it.

Clinical Care Management Overview

Clinical Care Management is a coordinated and proactive approach to providing personalized care for members with complex medical needs. When offered through a third-party administrator (TPA), CCM involves services designed to improve member outcomes, reduce healthcare costs, and enhance member satisfaction. It is a proactive and patient-centered approach to managing member health and helps improve health outcomes, reduce hospitalizations, and lower healthcare costs.

TPAs like HealthComp that offer CCM have a team of healthcare professionals, including nurses, social workers, care coordinators, and, in HealthComp’s case, an in-house medical director, who work collaboratively to provide personalized care for members. This team uses evidence-based care models and clinical protocols to ensure members receive appropriate medical attention and support. Members work with their dedicated care advocate using resources such as chronic disease management, behavioral health management, health coaching, maternity management, large case management, and utilization review to develop a care plan that addresses members’ medical, social, and emotional needs. A care plan may include coordinating healthcare services, providing education and support to the member and their family, and monitoring their progress over time.

CCM starts with identifying members with complex medical needs, such as those with multiple chronic conditions, at risk of hospitalization, or needing ongoing medical attention. Once members are identified, a care team is assembled to provide comprehensive care and support.

What are the benefits of having a Clinical Care Management program?

By providing personalized care and support to members with complex medical needs, clinical care management can help prevent complications, reduce hospitalizations, and ensure that members receive appropriate medical attention. One of the key benefits of having a CCM program is that it is a proactive approach to healthcare. Rather than waiting for members to become sick or require hospitalization, CCM focuses on preventing complications and managing healthcare needs before they become serious. Identifying potential health risks and addressing them before they become serious will help to improve the overall health outcomes of members and the employee population, reduce healthcare costs, and improve the quality of care.

What should you look for in a Clinical Care Management program?

When considering a CCM program through a TPA, you should look for patient-centered, evidence-based, and data-driven programs. It should provide personalized, coordinated, and comprehensive care to members.

Your chosen program should have a team of healthcare professionals with expertise in managing complex medical conditions. Pay attention to the patient identification and stratification process. The program should use risk stratification tools to identify high-risk patients of adverse health outcomes and provide patient education and support services to help members manage their medical conditions effectively. Effective communication and collaboration processes are essential to ensure that members, their families, and their healthcare providers are informed and engaged in the care process.

It’s important to consider programs that use evidence-based care models and clinical protocols to ensure patients receive appropriate medical attention and support, staying current with the latest clinical guidelines and best practices.

The CCM program should also have robust data analytics and reporting capabilities to track patient outcomes, monitor program effectiveness, and identify opportunities for improvement. A continuous quality improvement process is also necessary to evaluate program effectiveness, identify areas for improvement, and implement changes as needed.

Your CCM provider should offer actuarial validation of their results that consider the unique nature of the population reviewed, including an adjustment for risk and geography. Actuarial validation, particularly when provided by an external reviewer, is crucial when evaluating a clinical care management program. This validation assesses the program’s financial impact and cost-effectiveness and helps determine if the program generates savings that justify the costs. Factors considered in actuarial validation include program costs, baseline healthcare costs, impact on utilization, cost savings, and health outcome improvements. By obtaining actuarial validation, employers can ensure transparency and make informed decisions about the value and financial implications of the clinical care management program.

Why should I consider purchasing Clinical Care Management through my TPA?

CCM services offered through a TPA can provide a range of benefits to employers, including better management of healthcare costs, improved employee health outcomes, increased employee satisfaction, access to healthcare expertise, customization to fit the employer’s needs, and data analytics and reporting capabilities.

A CCM built directly within the TPA’s infrastructure ensures tight integration, efficient processes, and enhanced customization. A TPA like HealthComp can leverage existing infrastructure, technology, and relationships with healthcare providers to streamline the implementation and delivery of CCM services. The TPA has full control over the program and can align it closely with existing services, such as utilization management and claims administration. They can also provide comprehensive reporting and analytics, integrating CCM data with other healthcare data for a holistic view of employee health. Customization in plan design can be achieved through collaboration with the TPA, as they understand your unique population and can tailor the program accordingly. This customization leads to improved engagement, reportability, and customization to fit the specific population the TPA serves.

Ultimately, choosing between purchasing CCM through your TPA or a TPA’s in-house CCM will depend on factors such as the TPA’s capabilities, your specific requirements, and the level of integration and customization required by the plan. It is important to have open and transparent discussions with the selected TPA to understand their offerings, capabilities, and how they can best support your clinical care management needs.

What should you expect from a Clinical Care Management program?

Brokers and their employer clients should expect a robust system that delivers tangible results in enhancing the health and well-being of the workforce. As employers increasingly recognize the correlation between a healthy workforce and productivity, the right CCM program becomes paramount. Such programs need to effectively promote a healthier workforce, not only leading to reduced absenteeism but also to a considerable reduction in overall healthcare costs. You should expect to see higher engagement rates from a TPA CCM program. An efficient CCM system translates to higher employee satisfaction as individuals feel valued and cared for, resulting in better retention rates. It’s vital for brokers and employers to seek out programs that provide evidence-based outcomes, ensuring that the financial investments made in these programs yield the desired returns in the form of a happier, healthier, and more productive workforce.

From the employee’s perspective, the advantages of a CCM program are manifold. The program should offer personalized care tailored to individual needs, ensuring that every employee gets the required attention and care. This individual-focused approach leads to improved health outcomes, reducing the risk of chronic diseases and related complications. Furthermore, a good CCM program should guarantee better access to healthcare services, bridging any existing gaps in care and ensuring timely interventions. Lastly, knowing that their health is being actively managed and monitored, employees experience invaluable peace of mind. In essence, a CCM program acts as a bridge between employers’ objectives of cost savings and workforce productivity, and employees’ desires for personalized care and improved health. This creates a symbiotic relationship where both parties thrive and reinforces the narrative that investing in employee health is a strategic business decision.

Clinical Care Management Success

A healthcare trend will quickly lose traction if it doesn’t provide the desired results. Balancing co-existing desired results – a healthier population and a healthier bottom line – isn’t always a possibility. With CCM, both members and health plans benefit.

In HealthComp’s own CCM program, offered through our Elevate product, we’ve seen significant results. In 2021, CCM data was analyzed by an outside firm and compared to a similar population demographic. Overall utilization in the compared group was 30% lower, with a 14% reduction in outpatient utilization, gained by engaging members and improving treatment selections to favor lasting results. Inpatient charges were 48% lower, representing a savings of $14.25 per employee per month (PEPM). This was achieved by helping members with chronic conditions create healthier habits and teaching them to make more sustainable health decisions to avoid acute exacerbations and prevent readmission. Our Emergency Room Solution services saw 32% lower usage rates compared to the metropolitan sample, representing $16.09 PEPM in savings.

Even in larger operations like Medicare and Medicaid, there is a benefit seen to using CCM as a means of managing medical costs. Medicare sees a dollar impact of $28 per beneficiary per month because of its CCM program. A recent McKinsey study showed payers may generate more than two-to-one (2:1+) ROI by expanding their care management tools. For every $1 invested, plans could see a $2 return, while also ensuring a better, healthier experience for members.

Based on the results seen by HealthComp, CCM as a cost management solution produces results. Trusting your clients and their benefits plans to HealthComp allows you to take advantage of the knowledge we’ve gained through our decades of experience. While the industry may follow trends, HealthComp follows the data. Effective plan management and high-result cost-saving solutions like CCM show this is anything but a passing fancy.

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