What does managed care even mean these days? As the field has ballooned, its substance has been diluted, though it will still be useful in the new healthcare economy.
"The term 'managed care' is dangerously close to meaninglessness, and unlike pornography, as famously stated by United States Supreme Court Justice Potter Stewart, we may not even recognize it when we see it," argues Commonwealth Fund president David Blumenthal, MD, in a fitting venue, the Journal of American Managed Care.
Some 40 years since the HMO was born and barely 30 years since the term managed care was coined, the field is a hodgepodge of healthcare financing and delivery designs, Blumenthal writes.
"Group Health Cooperative of Puget Sound, Kaiser Permanente, and Geisinger are managed care organizations," he notes. "But so are Medicaid plans that--after taking a cut--pay the clinicians' fee for service and call it a day. The MCO alphabet soup has come to include HMOs, PPOs, ACOs (MSSP and Pioneer), MA plans, PCMHs, IDNs, IPAs, and who knows what else."
Indeed, Blumenthal, the former chief information officer at Partners HealthCare in Boston, argues that the idea of managed care "seems to run crosswise of the emergent trend toward patient engagement in and control over the care experience."
At the same time, management is everywhere in healthcare--of patients with chronic illnesses and acute conditions, of medical practices and hospital revenue cycles, of employee benefits.
Thus, Blumenthal argues, the industry should "retool the term managed care for the 21st century." He suggests three areas to think about the future, and making managed care useful to patients and taxpayers.
Clinical benefits management
"Clinical benefits management," Blumenthal writes, include services with value supported by evidence, also known as clinically-nuanced benefits or value-based insurance design.
Using comparative effectiveness research, "benefits management should exclude or discourage the use of services shown to be unsafe, ineffective, inferior to alternatives, or not cost-effective," according to Blumenthal. This should come with incentives (cost-sharing or reduced-cost sharing) to "nudge" patients toward services with the most supporting evidence, such as medications for diabetes, hypertension or asthma, he argues.
Clinical management
Then there is clinical care management, what Blumenthal describes as managed care organizations working with nurses and physicians to apply clinical strategies "likely to result in better-coordinated, cost-effective, patient-responsive, and high-value services."
Among these strategies are proactive management of chronic conditions between visits to a facility; care teams with a variety of clinicians for different levels of care; an emphasis on shared decision making and the patient experience; information systems with predictive tools to identify at-risk patients and patient registries to help build evidence bases; and considerations of nonmedical determinants of health, such as housing and social networks.
These techniques "can be employed in any setting, but are likely to be easier and more successful when supported by an infrastructure that enables collaboration and information-sharing across providers, between patients and providers, and even among patients where appropriate," Blumenthal writes. "This infrastructure can be provided by external organizations or developed in-house, but will always need to be tailored to the local contexts."
Patient engagement
Finally, there is managed care's purview in one of healthcare's much hyped idea--patient engagement, the "blockbuster drug of the 21st century," as dubbed by digital health strategist Leonard Kish.
Blumenthal argues that it's worthwhile to "broaden the concept of care management to include patients as managers of their care experience," especially patients with chronic conditions that can be successfully self-managed. "For this reason, patient engagement is the third domain of managed care."
Like clinical management, Blumenthal argues that patient engagement needs an infrastructure, and in fact it is already available.
"One area where this infrastructure is rapidly developing is the growing market of consumer-directed health information technology products. Patient portals, for example, allow patients to remotely connect with their clinicians or access their medical records, and OpenNotes developers are experimenting with enabling patients to add to provider records. Important new opportunities are arising for patients to voluntarily augment their health information through apps, smart watches, biosensors, and other innovations coming down the tech pipeline."
Relatedly in patient engagement is patient empowerment through transparency; "give them reliable information on quality and cost," Blumenthal argues. "Such information is currently mostly unavailable or shielded behind proprietary contracts. Having it available when patients need it and in a form that they can understand is necessary for them to make treatment choices and fully participate in shared decision making."