Abstract
BackgroundCare coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model. Research exists on opinions of providers of care coordination but there is limited information on perspectives of those in the insurance industry about key elements. We sought to gather opinions from primary care providers and administrators in Minnesota who were involved in a CMS (Center for Medicare and Medicaid Services) transformational grant implementing COMPASS (Care Of Mental, Physical And Substance-use Syndromes), an evidence-based model of care coordination for depressed patients comorbid with diabetes and/or cardiovascular disease. We then sought to compare these views with those of private insurance representatives in Minnesota.MethodsWe used qualitative methods to conducted forty-two key informant interviews with primary care providers (n = 15); administrators (n = 15); and insurers (n = 12). We analyzed the recorded and transcribed data, once de-identified, using a frameworks analysis approach.ResultsWe identified six primary themes: 1) a defined scope, rationale, and key partnerships for building comprehensive care coordination programs, 2) effective information exchange, 3) a trained and available workforce, 4) the need for a business model and a financially justifiable program, 5) a need for evaluation and ongoing improvement of care coordination, and 6) the importance of patient and family engagement. Overall consensus across stakeholder groups was high including a call for payment reform to support a valued service. Despite their role in paying for care, insurance representatives did not stress reduced utilization as more important than other outcomes.ConclusionsPrimary care providers and administrators from different organizations and backgrounds, all with experience in COMPASS, in large part agreed with insurance representatives on the main elements of a sustainable model and the need for health reform to sustain this service.
Highlights
Care coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model
We identified insurers beginning with information on market share of the private insurance market obtained from the Minnesota Department of Health Economics Program analysis of the Minnesota Comprehensive Health Association (MCHA) premium database for 2013
Examples of patient characteristics considered most appropriate for care coordination include medical (diabetes, chronic obstructive pulmonary disease (COPD), cardiovascular, kidney diseases), behavioral, psychological, and/or social factors
Summary
Care coordination has been a common tool for practices seeking to manage complex patients, yet there remains confusion about the most effective and sustainable model. We sought to gather opinions from primary care providers and administrators in Minnesota who were involved in a CMS (Center for Medicare and Medicaid Services) transformational grant implementing COMPASS (Care Of Mental, Physical And Substance-use Syndromes), an evidence-based model of care coordination for depressed patients comorbid with diabetes and/or cardiovascular disease. Care coordination is a model of healthcare delivery created out of the growing awareness of the prevalence and cost of chronic conditions among patient populations [1], and the fragmentation [2] and limitations of a healthcare system organized around fee-for-service and acute care [3, 4]. In the complex world of routine clinical practice there are at least 40 definitions of care coordination [8] resulting in confusion as to what components of care coordination are necessary to attain desired outcomes. For care coordination to succeed in a fee-for-service world where patients depend on commercial insurance, insurers must recognize at least some levels of care coordination as a reimbursable service [12]
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