Follow Michealle Linkedin
Email Michealle Email
Health Care
Aug 23, 2021

Back To Basics: Revisiting The Fundamentals of Medicaid Transformation as it Relates to Patient Care

Sponsored Content provided by Michealle Gady - Founder and President , Atromitos

North Carolina is about six weeks into the launch of Medicaid Transformation. Many of us are focused on the implementation of managed care, which is foundational to Medicaid Transformation. As a refresher and for definitional purposes, managed care is a capitated, risk-based contracting between the state and health insurance companies for the delivery of (nearly) comprehensive medical services for a given population.   As such it is a big change from our previously exclusively “fee for service” delivery system where all costs were met directly by the State.
As with any major system change, it’s not going perfectly. Providers are having trouble getting claims through. Patients are assigned to the wrong primary care provider. Prepaid Health Plans are struggling with IT systems that aren’t working as planned. The list goes on.
North Carolina isn’t the first state to launch managed care. So, we have lessons learned that we can turn to from other states. We will all work through these issues. In fact, NC DHHS is already revising policies and putting in place temporary support programs to help the provider community. (See the Extension of Out of Network Provisions bulletin and the Expedited Hardship Advances for Managed Care Providers program.)
But that isn’t the purpose of this article.  I am confident in the endless resourcefulness of necessity. I am afraid, however, that in the midst of the increased administrative burden and financial strain that all stakeholders are experiencing, we are missing an important, foundational opportunity: that is another pillar of North Carolina’s Medicaid Transformation – Improving population health through patient-centered, whole-person, provider-led care management through the Advanced Medical Home model.
The Advanced Medical Home (AMH) model, as developed by North Carolina is predicated upon the premise of the primacy of the relationship between a patient and their primary care provider.  Care management, or the systematic approach of a health care team to manage health conditions in order to achieve an optimal level of wellness while providing cost-effective, non-duplicative services, is at the core of NC’s innovative AMH model. 
At Atromitos, we’ve worked with providers of all shapes and sizes on developing care management programs. In all frankness, some providers “get it” – but most don’t.  Recognizing this has forced me, over the last month or so, to step back and to think about how we present and frame care management to providers and their patients.  And that is the purpose of this article – to return to the basics, starting with some definitions, so that as stakeholders we can better strive toward achievement of our shared objectives of improved outcomes, better care, and increase patient and provider satisfaction.
The Agency for Healthcare Research and Quality (AHRQ) calls care management a fundamental vehicle for managing the health of populations.
Let’s start by defining Care Management.
What is Care Management?
Care Coordination. Disease Management. Chronic Condition Management. Case Management. Care Management. Complex Care Management. Transitional Care Management. Discharge Planning. Are these the same things? Different? Are they related?
While these are terms that define different processes and objectives, they are all related. And, of course, in health care, depending on the context, the terms may be defined differently. I think what is important to understand is that Care Management is not Care Coordination. Put simply, care coordination is the non-clinical navigation of health care delivery across a fragmented continuum of care, with the objective of reducing gaps in care. Many providers already provide some level of care coordination to their patients, but most do not provide care management.
I prefer the definition of care management developed by the Center for Health Care Strategies:

  • Care Management: Care management programs apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively. The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost-effective, non-duplicative services.
What is most important in this definition is the acknowledgment of the role of systems in care management. That’s because care management, when done correctly, includes a data-driven process of identifying patients that need care management, stratifying to determine what appropriate level of care management is needed, and then prioritizing patients based on their level of need. Once the level of need is known, the care management team (yes – TEAM) deploys evidence-based interventions to support the patient and their caregivers in achieving the best health and wellbeing that the person can achieve.   Care Management, in short, is an intersection of data science, the clinical team, and behavioral science.  That is a lot more than coordinating appointments across different providers.
What are the benefits of Care Management?
A lot of people argue that care management leads to reductions in health care cost growth. Maybe it does. Those that have worked with me in this area know that I don’t think so. Not unless you’re playing the long game. That’s because to develop, implement, and operate a successful care management program, providers must make direct investments in the right information technology, hire and continually train the right personnel (and not just care managers), and engage in continuous quality improvement activities to ensure that the program is operating as it should and delivering the services that are needed.
I do think, though, that care management makes a difference to patients, their caregivers, and the health care providers that are providing the care they need. Here are three benefits of care management that I know, from direct experience, occur because of care management:
  1. Improved patient and provider relationships.
  2. Increased patient self-management.
  3. Improved quality of care and care experience.
Top 3 Provider Considerations
Having defined our terms and established their importance as it relates to creating a more equitable, effective, and sustainable environment for health, the next question is what we do now.  The AMH model presents an important opportunity for providers to invest in population management systems to improve the quality (and experience) of care at an individual level.  The following are the three lessons I have learned over 15 years of designing, implementing, and evaluating care management systems.
  1. Care Management Requires Investment.
I cannot overemphasize this enough. Effective, integrated care management (the kind that is expected by NC DHHS) represents a fundamental system change, moving from reactive and discrete interventions to a more systems-driven, collaborative team-based approach. If providers think they can get away with implementing a care management program with little or no financial and other resource investment, they are badly mistaken. It perhaps took NC DHHS longer than it should have to realize this, but that is why earlier this year, providers that attested at the AMH Tier 3 level received “Glidepath Payments” to help defray the cost of establishing a robust care management program. It is why the care management fee that the Department indicated to the Medicaid Prepaid Health Plans is so high. And, yes, it is high. In other contexts, I’ve worked with organizations providing care management for around $4.00 PMPM. That is less than half of what many providers in NC are being paid under the AMH model and it is even less if you factor in the medical home fees that providers also receive.
  1. Care Management Requires Information Technology Specific to Care Management
Many providers insist that they can use their existing electronic health record (EHR) to engage in the necessary risk stratification, assessments, care planning, intervention documentation, and then performance reporting. They can’t. Under NC Medicaid’s AMH model, which aligns with the AHRQ care management recommendations, providers must have the ability to receive substantial amounts of data from the PHPs (claims data, patient risk lists, etc.). That data must be stored somewhere, safely and securely, like in a data lake. It then needs to undergo ingestion into a system, where it is cleaned and then quality checked to make sure the data is useful, readable, complete, and in the right place. And that is just one source of data. Other sources include ADT notifications from NC HIE (and if you are in Medicaid region 5 CC HIE). That’s a lot of data and a lot of integration. But that is what makes care management what it is meant to be. You must have a clear view of the patient and all their needs, care, etc. You then need to use that information to evaluate the risk level of your patient – risk stratification. That requires sophisticated algorithms.
A care management documentation system not only integrates data from a variety of sources to create that 360-degree view of the patient but it also is built for appropriate care management workflows. From initial patient engagement to regular reporting of performance on service levels and quality metrics. It is paramount that your care management team have efficient workflows and systems that support those; otherwise, they will not only waste valuable time, but they – and the patient – will get frustrated, which means that the improved experience of care that care management can provide won’t happen. (It’s also going to lead to high turnover among your staff.)
In addition, you will need to invest in the right equipment for your team. The part of the team directly engaging with the patient will need to have equipment that allows them to be mobile – to visit patients at the hospital, in the community, or at the clinic. But, working across multiple systems as they will be required to do, will also require them to have large monitors so that they can have multiple screens open and in front of them, which makes working efficiently more possible – but also prevents errors from happening. Your care management team will also need a printer – and you need to decide how to do that if your care team is based in an office or remotely or a hybrid. And they will need the ability to mail communications to patients and receive them back in a safe and HIPAA compliant way.
  1. Care Management Requires the Right Team of Professionals
Now, about that team. Care management is a team process. It’s not the job of a single person. It requires nurses, behavioral health clinicians, and pharmacists, as well as quality, compliance, IT, operations, and non-licensed support staff. NC Medicaid is very clear that a team-based approach is required as part of the AMH Tier 3 model. Additionally, the care management team must comply with state scope of practice laws.
Therefore, you need to hire a team that not only meets the necessary license and other credential requirements, but those that are adaptable, flexible, compassionate, empathetic, self-directed, and persistent. I once had a client ask, “Can’t we just hire people and then train them to do the job?” Sure. You can hire people with the right credentials and train them to do that job. But you’re just training them to do the letter of the job. Not the spirit of the job. A deeply experienced care management professional explained to me that to be a care manager requires the person to be an investigator that won’t ever give up. That person doesn’t just ask the assessment questions but knows how to ask the right questions in a way that will get the needed answers. They don’t just know how to write up goals that meet the identified needs but will go to the ends of the earth to find the support and resources the patient needs to achieve those goals.
Finally, once you’ve hired the right team, you need to continually invest in their ongoing training and education. Not only do all the PHPs require, in contract, that the care management team have certain kinds of training (ex. trauma-informed care, Adverse Childhood Experiences, cultural competency, etc.), but to ensure that you are providing effective care management (read: evidence-based interventions), your team will need to remain abreast of new developments and ways of supporting patients, caregivers, and providers.
In conclusion, care management, as envisaged by NC DHHS through its AMH model represents a fundamental “transformation” of care delivery in North Carolina, and effective care management is at the center of that transformation.  Transformation is hard, it is messy, and it is expensive, but that doesn’t mean that it isn’t necessary or rewarding.  While all of us in the Medicaid space today are struggling to adapt to the daily administrative challenges that come with the transition to managed care, I would encourage us all to remember the “why” – and to not lose sight of the big picture or the forest – despite a few forest fires.
North Carolina’s Care Management Strategy under Managed Care
AMH Manual 2.1
AMH Data Specification Guidance
Michealle Gady, JD, is Founder and President of Atromitos, LLC, a boutique consulting firm headquartered in Wilmington, North Carolina. Atromitos works with a variety of organizations from health payers and technology companies, to community-based organizations and nonprofits but their work reflects a singular mission: creating healthier, more resilient, and more equitable communities. Michealle takes nearly 20 years’ experience in health law and policy, program design and implementation, value-based care, and change management and puts it to work for Atromitos’ partners who are trying to succeed during this time of dramatic transformation within the U.S. healthcare system. Outside of leading the Atromitos team, Michealle serves as a Board Member for both the Cape Fear Literacy Council and A Safe Place and is a member of the American College of Healthcare Executives and American Health Law Association.

Gwbjblockad 13122111851
Ico insights



What New HOA Board Members Need to Know: A Comprehensive Guide

Dave Orr - Community Association Management Services
Pfinder john zachary

Back to the Basics: Required Minimum Distributions

John B Zachary - Pathfinder Wealth Consulting

Risk Tolerance vs Risk Capacity

Jason Wheeler - Pathfinder Wealth Consulting

Trending News

Coming To Mayfaire: New Tenants, Lululemon Expansion And Rolex Time

Staff Reports - Jun 14, 2024

In The Current Issue

Potential Swells For More Swimming

As the population increases, demand continues to grow for pools the public can access in Wilmington and New Hanover County....

CFCC, UNCW Expand Programs

Health care industry training programs have been getting a boost....

Home Options: Stage Set For Accessory Dwelling Units To Proliferate

Defined as a separate residential living space on the same lot as a primary dwelling, the topic of ADUs is seeing a resurgence in the Port C...

Book On Business

The 2024 WilmingtonBiz: Book on Business is an annual publication showcasing the Wilmington region as a center of business.

Order Your Copy Today!



2024 Power Breakfast: The Next Season