4 Ways APC Overcomes The Pitfalls Of Managed Care

Early versions of managed care meant well. They were created to centralize care and achieve better health outcomes while controlling costs, but things didn’t go as planned. Instead of controlling costs, managed care controlled access to care and, in some cases, also fueled cycles of wasteful spending. This article released by Stanford Business does a great job exploring the details of what exactly went wrong. Lack of choice, spiralizing levels of complexity, and poor collaboration between doctors and insurance companies all played a role in the deficiencies of managed care.

Advanced primary care (APC) delivers on the promise of managed care and much more, with a model focused on members’ health outcomes rather than the volume of care transitions and related claims. This effectively flattens costs and improves the member experience. Here are four ways ACP improves on health outcomes and avoids the drawbacks of managed care:

1. Corrects the limitations of managed care

While managed care never worked as intended, the intentions behind the model were good. It was meant to manage care more proactively and to provide coordinated care and help guide members through their care journey.

To be truly effective for an employer’s bottom line, as well as for health and wellness, managed care must be about more than a centralized member experience. The care provided through primary care must be positioned at its core. This should include:

• A “medical home” model with improved accessibility for members and employees
• Health engagement for all members and employees, which improves the risk stratification for the entire population
• Relationship-based integrated care, including health coaches and behavioral health clinicians
• Real-time data analytics for improved care coordination 
• Organization-wide behavior change to support health and wellness

There’s nothing incidental about primary care, its providers, and its services. In fact, the industry is starting to understand just how essential primary care and its providers are for members, even in cases where specialists are needed.

2. Improves managed care through care coordination

Care coordination corrects the misalignment of outdated managed care models by making primary care physicians (PCPs) and their care teams the focal point of the care experience, rather than restricting primary care teams by facilitating referrals to specialists. 

Effective care coordination includes the following benefits: 

• Maximizing the amount of care within the amply equipped, fixed-cost environment of primary care
• Controlling costs by referring employees out to appropriate high-quality, low-cost specialty networks only when necessary
• Improving communication and anticipating member and employee needs 

Care coordination means primary care teams work proactively to identify when a member or employee needs specialty care. It also ensures specialists provide the primary care team with data regarding visits, allowing the care team to follow up with patients regarding their care plans. This improves the member experience and reduces gaps in care that were all too common in earlier versions of managed care.

3. Addresses the specific needs of at-risk populations

Care coordination is especially important for at-risk populations in their 60s, 70s, and 80s who tend to have more than one condition (like high blood pressure and diabetes) and are more likely to fall behind on screenings. It allows care center teams to collaborate on:

• Identifying the needs of each patient
• Offering health coaching when applicable
• Determining when specialist care is required
• Providing in-depth information on medical conditions to specialists
• Ensuring patients are well taken care of when they return to care centers

“This situation requires strong care coordination,” says Dr. Kevin Wang, Vera’s Chief Medical Officer. “You have to have a model in which primary care is the hub that drives the right referrals when needed but also quarterbacks the patient's care.”

4. Creates a coordinated care hub

APC establishes primary care centers as the hub (rather than a brief pitstop) where 80-90 percent of all care-related needs can be achieved. The entire APC model is driven by data to determine, plan, and staff a care center team that can best meet the actual needs of the population they’re serving. 

Care coordination is helped when APC services work together to reduce overall costs and drive real, measurable improvements in health outcomes.

• Virtual care increases access and convenience so that members can more readily achieve their health goals in trusting relationships with providers

• Behavioral health clinicians provide support for mental health, addictive disorders, and more — contributing to mental and emotional well-being 

• Health coaches encourage members to improve lifestyle choices that otherwise account for 70% of all healthcare costs

A better approach to providing care

APC and care coordination correct for the costly inefficiencies, care gaps, and underutilized PCPs of managed care. It’s no wonder reputable predictions about the future of healthcare look a lot like APC’s proactive, patient-centered model. 

It’s not enough to cut costs and increase control. At the end of the day, APC overcomes what managed care could not, because it prioritizes health outcomes, flattens costs, and improves the member experience.