The system is broken. They’re fixing it.
Quality of care is the name of the game, and the players in our fragmented healthcare system are increasingly focused on improving coordinated care across all settings in order to meet this goal. Among healthcare organizations, CareMore, a California-based Medicare healthcare company, is making population health management work. Acquired by WellPoint, one of the nation’s largest health insurers for $800 million in 2011, CareMore’s business and operating models converge in a novel care delivery model that aligns incentives within capitation plans.
Across the spectrum from preventive health to management of complex, chronic disease, CareMore accomplishes the goal of reducing costs of high quality care for the aging population via coordinated operations of human capital:
- Education and Behavioral Health Experts – Enrolled patients benefit from support groups, nutritional education, and counseling. Because CareMore bears the cost of total medical care, they are incentivized to invest in and provide prevention programs with the goal of curbing the progression of chronic diseases and their downstream costly interventions such as dialysis.
- Extensivists – Physicians who provide continuous support during and following hospitalizations redefine the process flow of inpatient care by shortening the length of stay in the hospital and minimizing information hand-offs and the potential for medical error or inadequate follow-up.
- Specialists – High-cost specialist care is reserved for when it is truly necessary in order to limit redundancy and confusion for patients.
- Drivers – Low-cost investments in providing transportation for patients to and from the center limits missed appointments and the need for hospital visits.
The benefits of these changes are already evident, with CareMore’s rates of patients requiring rehospitalization within 30 days down to 12% compared to the national average of 20%. Less time in the hospital translates to higher quality of life for patients and profits that can be reinvested in preventive measures.
Opening the Doors of Innovation and Communication
In an ecosystem dominated by payer-provider negotiations, CareMore reduces friction by integrating both roles. According to CareMore Chief Medial Officer, Sachin Jain, “Our edge comes from the fact that we are the payer and provider for our patients. Rather than waiting to find out whether insurance companies will pay for a new program designed for diabetic patients, we can roll it out on our own timeline and terms.”
By doing this, CareMore has control over quality and efficiency of program activities. Moreover, their customized electronic health record both facilitates communication between CareMore members and community providers and enables CareMore to collect data on their own patients for more immediate and rigorous evidence-based feedback on the efficacy of their innovations and where there is a need for improvement.
CareMore is looking to capitalize on a growing trend in which people are increasingly buying healthcare based on value. This market is expected to grow from $232 billion to $3.7 trillion by 2025, and CareMore’s approach to expansion further demonstrates alignment of its business model and operations. So far, CareMore has expanded to provide the Medicare Advantage plan to its members across eight states. CareMore develops centers in regions with considerable interhospital competition where they can better function in a climate conducive to payment negotiations. Resource allocation is then tailored to meet the new scope of patient demographics through educational program design and employee selection based on language needs and cultural competency.
CareMore recognizes its employees as its strongest asset and helps care providers maintain relationships with their patients over a longer period of time than a single episode of care. Recruitment efforts targeted at physicians motivated to work in a pay-for-performance environment and offer competitive compensation. Doctors derive increased satisfaction from work in which they are functioning at the top of their license, which translates into increased retention and an upward spiral of enhanced longitudinal relationships, patient satisfaction with their care, and investment in their personal health.
With these strategies in place, CareMore’s inventive alignment of business model and operations is positioned to meet the dual challenge of reducing costs while improving patient outcomes and quality of life.
An interview with CareMore Chief Medical Officer Sachin H. Jain, MD, MBA about CareMore’s future direction.