As traditional healthcare models became known for escalating costs, the industry tried to do more for less. But in trying to correct for cost hikes, those very same fee-for-service models forced primary care providers (PCPs) into roles as gatekeepers for specialty care. Reduced health outcomes, diminished care experience, and provider burnout followed.
By taking a closer look at the old way (managed care) and the way forward (care coordination), we can better understand their key differences and how these very different approaches impact health outcomes and costs.
The managed care model was created to centralize member care within a single provider system as a way to achieve better health outcomes while keeping payer costs down. Members had to see their PCP in order to get a referral to an in-network specialist — regardless of that specialist’s quality or cost.
Managed care had the unintended outcome of perpetuating a cycle of wasteful spending. Insurance companies wouldn’t reimburse PCPs for treatment they were trained to do and had been doing successfully for years prior to the managed care model.
As a result, PCPs were forced to refer patients to specialists. Too often, patients would continue receiving care from specialists that could have been accomplished by their PCP. If patients did return to their PCP at some point, they would often be referred out to another specialist as new concerns emerged.
Care coordination makes PCPs and their care teams the through-line for a patient’s care experience. Unlike managed care, care coordination empowers primary care teams to identify when a patient needs specialist care and to ensure their return visit to a primary care center doesn’t miss a step.
It’s especially important for at-risk patients in their 60s, 70s, and 80s who, like many adults, fall behind on screenings and tend to have more than one condition (like high blood pressure or diabetes). Where managed care created gaps in follow-up treatment and needlessly influenced costly claims and less effective treatment plans, care coordination solves these problems by improving communication and anticipating patient needs in primary care centers.
Care coordination and advanced primary care (APC)
In an APC model, integrated care coordination lives in primary care centers — which are equipped to deliver 80-90 percent of all care. Members connect with care center providers and health coaches through in-person or virtual appointments, making it convenient to develop a personalized care plan focused on improving the members’ long-term health.
Longer appointments allow for meaningful conversations that address the root causes of any health issues. This approach is particularly beneficial for members with chronic conditions or symptoms that can often be alleviated by making positive lifestyle choices.
When patients do need to be referred out to a specialist, providers use high-value, low-cost specialty networks, allowing them to steer patients to the appropriate specialist that reduces overall costs for payers and organizations.
Care teams can schedule and manage specialty appointments as well as coordinate necessary follow-up so that specialty plans are integrated back into the member’s overall care plan.
With care designed to meet the needs (and realities) of members’ busy lives, care coordination in an APC model equips members to take greater ownership of their overall health. Members know they’re supported by an entire team, giving them further encouragement and peace of mind. Where managed care tried, care coordination succeeds at shoring up the member experience to deliver improved health outcomes and reduced overall costs. Because nothing as important as health should ever fall through the cracks.