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Themes from Innovative Complex Care Management Programs

solutionIn many regions across the country, robust “super-utilizer” programs providing intensive outpatient care management to high-need, high-cost patients are beginning to emerge. The term “super-utilizer” describes individuals whose complex physical, behavioral, and social needs are not well met through the current fragmented health care system. As a result, these individuals often bounce from emergency department to emergency department, from inpatient admission to readmission or institutionalization—all costly, chaotic, and ineffective ways to provide care and improve patient outcomes.

The Center for Health Care Strategies (CHCS), in partnership with the National Governors Association, hosted a Super-Utilizer Summit on February 11 and 12, 2013. The Summit brought together leaders from super-utilizer programs across the country, states, the Centers for Medicare & Medicaid Services, the Robert Wood Johnson Foundation (RWJF) Aligning Forces for Quality (AF4Q) alliances, health plans, and other key stakeholders to share strategies for changing how our health care system interacts with these high-need, high-cost patients.

This report presents the Summit’s common themes and key recommendations for building better systems of care for high utilizers. The appendices also include materials related to existing complex care management programs that can be educational resources for states and policy-makers considering ways to implement, spread, and sustain such programs.SuperUtilizersSummitReport 2013

Goodbye UR, Hello “Quality Improvement”

With the interim final rule (MLRFinalInterimRule 11-22-2010) defining allowable costs to meet the health plan medical loss ratio (MLR) requirements under healthcare reform published on December 1, 2010, the federal Department of Health and Human Services (HHS) has given the managed care industry a significant incentive to evolve their utilization management practices.  Under the Rule, health plans can include the costs of quality improvement activities as a medical expense toward the MLR, but not the costs of retrospective and concurrent utilization reviews.

Some health plans will no doubt attempt to re-label and slightly modify UR activities and argue that it is quality improvement but the most plans will likely shift focus to more pro-active care management, and clinical consultation for protocol outliers.  This will also be consistent with the growing focus on evidence-informed and evidence-based practices.

Now is the time for providers to start the process of revamping their own utilization review processes to focus on quality improvement rather than utilization controls or singular cost containment.

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