New Payment Models Reduce Reimbursement Challenges for Embedded Case Management

Understanding where a practice is and where it wants to go helps to ease the challenge of embedding case managers into physician practices, says Annette Watson, RN-BC, CCM, MBA, senior vice president of community transformation for Taconic Professional Resources. She explained this and other challenges that Taconic encountered when it launched Taconic Professional Resources, an entity dedicated to the support, management, training and evaluation of case managers co-located in physician practices.

Question: The Healthcare Intelligence Network’s (HIN) 2013 Healthcare Case Management Survey shows that staff buy-in, reimbursement and communication were the top challenges of embedding case managers into a physician practice. Has Taconic encountered similar challenges?

Annette Watson: Yes, those are three things consistent with what we hear when beginning to work with case managers in a practice. The staff buy-in and communication are something we work as part of our role as the embedding organization. We work with the practices on how they are changing and how they will introduce this person into their culture, as well as assess the practice before we get there regarding what they currently have in place for workflow and staff.

Those issues of communication and staff buy-in are part of our assessment and readying the practice for this person. One thing that makes these placements more successful is understanding where the practice currently is and where they are trying to go. Having Taconic involved and providing the support for not only the case manager but also the practice as they try to change the way they do things is helpful. We have been effective in addressing both of those issues the HIN survey identified.

The third issue of reimbursement is a little more complicated for practices. Many times the value of an RN is not something they typically have seen in their practice models. They are used to having people with clinical skills providing direct patient care that is reimbursable at the PA level or the mid-level RN, NPs and physicians. Often, they have not had a case manager in this type of role who worked to educate the sickest and most chronically ill patients in the practice.

The value of that role, and how that gets paid for out of the practice, is something we also work on when evaluating how this is working in a particular practice and identifying their goals. If they participate in new models of care like ACOs or some of the demonstration projects such as the CPC model, there may be funds flowing into the practice that allow for greater reimbursement that they can then utilize. Other private payors are doing similar things.

We don’t see reimbursement being as much of a barrier as it once was, given the new models of care emerging and the payment reform happening in the marketplace.

Source: Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot

Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot describes Taconic’s commitment to embedded case management as well as the motivation behind the new entity and the case management-related services Taconic Professional Resources makes available to more than 5,000 physicians in its open, multi-payor environment.

This entry was posted in Avoidable Hospitalization, Care Coordination, Care Transitions, Case Managers, Case Managers and the Patient Experience, Embedded Case Manager and tagged , , , . Bookmark the permalink.
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