Editor's note: Medicaid programs are increasingly driving delivery system transformation, changing how providers care for Medicaid populations and how they are paid for their services. Working with their community partners, providers have begun to develop a variety of innovative, person-centered care management models that attempt to better integrate the delivery system with critical social services—and the reinvention of care delivery is just beginning. In a recent webinar, "The Connected Patient: Using Digital Health in Care Management," Manatt Health explored how emerging care management models supported by digital technologies can help improve the health of Medicaid populations and the quality of care they receive, while also reducing costs. Key points are summarized below. To view the program free on demand, click here. To download a free copy of the presentation, click here.
What Is Connected Health?
Broadly speaking, connected health is a model for healthcare delivery that uses technology to provide healthcare remotely. Connected health aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and manage their own care. Connected health can cover a wide variety of areas. For example, it can be a way for life sciences companies to engage with patients, for researchers to collect patient-generated data, or for family and friends to build a support network to promote a patient's health and wellness. For connected health in care management to scale, however, selecting the right digital health tools for a targeted population is essential.
Because possibilities of connected health in care management are vast, this article focuses on the use of connected health for a particular target population: Medicaid patients. Not only are Medicaid patients a large, addressable population with particular needs, we believe connected health in care management for these patients will gain significant traction as a result of Medicaid-led reforms. Before turning to specific connected health solutions for this population, we provide an overview of "megatrends" driving the adoption of connected health solutions generally and an overview of these Medicaid-led reforms.
What Are the Megatrends Driving Connected Health Adoption?
There are five key megatrends driving the adoption of connected health:
- The shortage of physicians and nurses;
- The move to value-based care and payment;
- The ubiquity of consumer devices, making it possible to address disparities in access;
- Consumer demand for choice, including price and quality transparency, as well as increased convenience and personalization; and
- The aging population, requiring in-home care.
In addition, there are four key enablers of connected health adoption:
- The rise of HIPAA-compliant clouds that offer stronger levels of privacy and security;
- Emerging assessment standards that reduce friction between technology vendors and the covered entities;
- The rise of electronic medical records (EMRs) and the associated demand for interoperability and real-time data to drive actionable interventions; and
- The growing venture capital investment, with $8 billion currently invested in health technology companies.
What Are the Medicaid Trends Opening Opportunities for Digital Health?
Since Medicaid's creation in 1965, it has become the nation's main public health insurance program for the low-income population. The passage of the Affordable Care Act (ACA) in 2010 sought to expand Medicaid coverage to millions of previously uninsured adults and streamline enrollment. The ACA also emphasized the need for the Medicaid delivery system to transition to increasingly coordinated and innovative care models with the goal of achieving the "Triple Aim"—improved care for individuals, better population health and reduced costs.
As of February 2016, 30 states and Washington, D.C., have expanded Medicaid, and Medicaid is the single largest source of coverage in the United States. Most states that are expanding Medicaid are doing so through their existing delivery systems. In many states, that means expanding through managed care where states contract with managed care organizations (MCOs) to provide services to the Medicaid population. MCOs accept capitated payments or a set payment amount for the services they provide, encouraging the MCO and its provider network to effectively manage care and reduce unnecessary utilization.
As we think about emerging trends in Medicaid, expansion is certainly at the forefront, but expansion is happening in conjunction with delivery system and payment reform. New York's Delivery System Reform Incentive Payment (DSRIP) Program and Arkansas's multipayer, episode-based bundled payment program are just two examples.
Why Should Technology Be Integrated Into the Care Process?
The dynamic between patients and providers is quickly changing to include technology. Just as people are increasingly comfortable navigating between physical and virtual environments using their smartphones, patients are becoming increasingly comfortable using connected technologies to interact with their healthcare providers.
According to some studies, as many as 20% of patients actually prefer some form of electronic communication—such as video, email or texting—to an in-person office visit. Also, according to survey results released by the Office of the National Coordinator for Health IT (ONC), 81% of people who access their health information online found the information to be useful. ONC also found that people with online access to their electronic health records (EHRs) have a greater desire to do something about their health. Connected health solutions in care management therefore present additional avenues for patients to engage in their health, supported by their health teams.
What do providers think about patients and technology? A recent Accenture report found that providers have a favorable view of patients' technology adoption, reporting that it improved patient engagement, satisfaction and communication.
How Can Connected Health Technologies Be Integrated Into the Care Process?
Integrating connected health technologies into new modes of delivering care is a doubly daunting process and presents its own barrier to adoption. To overcome this barrier, it's worth learning from a real-world example of how it was done. We provide below a case study of how in-home remote monitoring technologies were adopted in a new care management program, and then consider other kinds of connected health technologies that are particularly well-suited to be integrated onto the same care management platform for Medicaid patients.
Case Study 1: Care Management With In-Home Monitoring
In 2012, the Health Resources and Services Administration (HRSA) awarded its first peer-to-peer grant for one federally qualified health center (FQHC) to teach another FQHC how to stand up and provide chronic care management services using in-home remote monitoring technologies. The project offers a model of how a DSRIP-funded project could be established to accomplish the same goals.
The Mentor: Roanoke-Chowan Community Health Center (RCCHC) is an FQHC operating in Eastern North Carolina in one of the poorest congressional districts, with a median income of just $23,500 and 21% of the population uninsured. As one might expect among low-income, poorly educated populations, there is a high incidence of chronic disease, such as cardiovascular disease, diabetes and hypertension. There also are significant barriers to care, including lack of transportation and poor health literacy.
RCCHC adopted in-home remote monitoring technologies—wireless weight scales, blood pressure monitors, glucometers and pulse-oximeters—into its care management program in 2006. Researchers from Wake Forest Medical School validated the positive clinical outcomes of its care management practice and published its findings in peer-reviewed journals. In the intervening years, RCCHC provided care management services to other healthcare providers in North Carolina through North Carolina's Telehealth Provider Network and began to contract with accountable care organizations within the state.
The Mentee: Mosaic Medical Community (Mosaic) is an FQHC in Oregon with 12 locations serving 23,000 patients, most of whom are enrolled in Medicaid. Mosaic did not have any care management workflows and was in the preparation stage of being connected to the Oregon Clinical Health Information Network (OCHIN), the health information exchange and shared electronic medical record for Mosaic and other members of Oregon's Coordinated Care Organization (CCO).
The Project: Under the HRSA grant, RCCHC's team of clinicians and project management consultants provided technical assistance on all phases of implementing a care management program with in-home remote monitoring but did not do so in a vacuum. At the same time, RCCHC worked with Mosaic to plan the transition of its care management program from a paper-based program to an automated workflow integrated with OCHIN. In addition, RCCHC worked with Mosaic to develop a train-the-trainer program, so that Mosaic can eventually train other members of the CCO to stand up their own chronic care management programs using in-home remote monitoring.
The RCCHC-Mosaic case study illustrates the complex environment in which connected health solutions have been expected to operate as other aspects of healthcare delivery are being transformed. Connected health adoption does not occur in a vacuum, but in an environment in which staff, clinical processes and information flows are continuously adapting to Meaningful Use and the transition to accountable care. These reasons highlight why HRSA grants, DSRIP and other sources of non-dilutive funding can accelerate the adoption of connected health solutions, and provide some runway before financial sustainability needs to be demonstrated.
For example, it took the RCCHC-Mosaic team two years to bring 212 patients into the remote monitoring program. While that number may not be large enough for financial sustainability, it was a robust enough sample to capture demographic data and quality metrics.
As of late 2015, most program participants were between the ages of 50 and 70, with diabetes and hypertension as the predominant conditions. Over 59% of the participants had two or more chronic diagnoses. Of the initial 212 participants, 76% or 161 patients successfully graduated or remained on the program. In general, significant reductions in blood pressure and A1c values were observed. At the same time, PAM scores—a validated tool to measure individuals' knowledge of their conditions and medications, confidence levels and willingness to make changes in their behaviors to improve their health—increased significantly. Emergency room visits also were reduced by 33% between the six months prior to enrollment and the six months after enrollment.
Case Study 2: Spot Monitoring a Single Biometric
In addition to conventional remote monitoring technologies used in a home, what other connected health solutions might work for Medicaid and uninsured populations? One example to consider is a wireless glucometer that is completely autonomous from a cell phone, such as the FDA-cleared glucometer from Telcare, which has its own cellular chip, so glucose blood readings can be transmitted automatically to care managers wherever patients are and not just in their homes.
In one pilot, a Medicaid managed care organization established a program to engage uninsured populations with diabetes in a state that had not yet accepted Medicaid expansion. The goal of the pilot was to engage and manage these populations before they became high utilizers in order to reduce emergency department visits.
To meet this objective, the MCO contracted with nonclinical community service groups to identify candidates and refer them to clinics. Candidates tested with an A1c value of nine or greater were provided with a Telcare glucometer, and assigned a nurse manager to provide instructions on how to use the glucometer, monitor them remotely thereafter, and use text messages through the device to interact with the patient. To date, over 1,000 patients have been enrolled in the program.
Case Study 3: Leveraging Consumer Mobile Devices
Another option to conventional in-home remote monitoring technologies is connected health solutions that leverage mobile devices that consumers already have. These options can be an attractive alternative, because they eliminate the need for expensive equipment and management of logistics for deploying, recovering and reprocessing the equipment.
According to Pew Research, 86% of households with annual incomes under $30,000 have cell phones and 43% have smartphones. These populations—which may be on Medicaid or uninsured—use text messages twice as frequently as populations in the $75,000 or more income bracket. Consequently, connected health solutions that engage Medicaid and uninsured populations not only have a cost advantage, but also leverage a preferred means for communicating with the outside world.
An example of this kind of solution is CareMessage, which draws deeply on research of human behaviors to support patients as they work on specific health-related challenges, including nutrition, exercise goal-setting and chronic condition management, as well as reminders for preventive care. An advantage of automated text messaging is its ability to leverage data analytics in real time to personalize and scale care management. Research also confirms that texting can reduce appointment no-shows, encourage the proper use of prescription drugs within a four-hour window, and motivate individuals to self-report their glucose readings.
Case Study 4: Connecting Patients to Community Resources
Finally, not all connected health strategies in care management relate directly to patient engagement and collection of patient health parameters. To manage whole Medicaid populations, managed care organizations and healthcare providers also need to leverage nonclinical resources. For these reasons, care management platforms are beginning to integrate solutions like Healthify. Healthify uses semantic search and the power of networks to make it easier for care managers to refer patients to appropriate community-based organizations and manage follow-up. Over time, more of these organizations can be expected to use connected health tools as part of their outreach and "boots on the ground" engagement.
Moving Ahead With Digital Health
As the examples illustrate, adopting digital health in care management is not a "one-off" program but rather is part of a multiyear, comprehensive care management strategy. Consequently, in considering these solutions, follow the same methodology used to select other health information technologies and develop new care delivery models.
First, where will the money come from to support the digital health program? It's important to consider the reimbursement model and how care management fits within that.
Second, what's the level of organizational readiness? There are a number of buckets to consider, including:
- Patient engagement (i.e., patient outreach and screening, care planning, care plan governance and provider support).
- Clinical supervision (i.e., provider network, protocol development and compliance, target population identification and performance monitoring).
- Workforce, staffing and training (i.e., workforce planning and development, and staff recruitment, deployment and training).
- Data and analytics (i.e., population risk modeling, data/trend reporting, metrics computation/tracking and partner performance feedback).
- Information technology (i.e., regional IT infrastructure and planning, implementation and help desk support, and central data management).
- Financial program management (i.e., network management/contracting, financial evaluation, sustainability and value-based payment planning, and fiscal agent/funds distribution functions).
Third, does the organization have the buy-in of clinicians? Clinician support and leadership are key to the success of digital health programs. When managing inpatient or ambulatory patients, connected health combines automated processes with clinician monitoring to serve as the bridge between the clinical information system and patent engagement.
Fourth, does the organization's internal development and planning support digital health? It's important to have a strong and shared point of view around key decisions:
- Select the beneficiary population. Choose the target audience—such as Medicaid patients, Medicare patients or employees—and agree on the metrics to measure effectiveness.
- Identify high-priority use cases. Analyze claims and health systems data to identify high-prevalence diseases within each population.
- Evaluate the potential impact of digital health solutions. Crosswalk high-prevalence diseases with digital health solutions to determine priority areas.
- Define prospective reimbursement models. Delineate possible models, such as risk taking, bundled payments, sub-capitation or case management fees.
Generating Value in the Short Term and Long Term
As we see in the Mosaic example, when creating a connected health program, it's important to identify some quick wins. Connected health is different than conventional approaches, so it's important to identify some interim wins the organization can build on as it moves to the later stages of program maturity. The key to success is establishing a methodical and realistic road map, recognizing that standing up a care management program is an iterative process. Below is a useful timeline to follow:
- Now. Establish an organizational structure to inventory, assess and prioritize digital health projects. Focus on identifying "quick wins" to establish buy-in.
- 6 months. Establish integrated clinical and information architectures, including creating internal development plans and identifying third-party partners. Complete case development and advance contracting discussions.
- 12 months. Implement activities that may not be reimbursable under the current financing structure but may increase volume or drive future revenue.
- 24 months. Analyze results of existing digital health initiatives, noting successes and failures. Expand in areas of high-growth opportunity.
- 36 months. Continue to expand digital health initiatives while continuously recalibrating based on the development of payment reform and new opportunities to improve outcomes.
There are six key success factors that must be in place to ensure the effective implementation of a connected health program:
- Gain leadership from clinicians and have a strong governance model in place.
- Understand the reimbursement model toward which the organization is working.
- Define physician incentives and performance metrics and align them with the reimbursement model.
- Establish the technology and monitoring infrastructure to support the selected measurement and reimbursement models.
- Conduct all legal, regulatory and security reviews.
- Finalize contracts in support of new arrangements and collaborations to drive clinically integrated care.