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Making Total Cost of Care Contracting Work

By Philip Betbeze  
   December 03, 2015

Sachin H. Jain

Models are payer-specific, but broadly, total cost of care contracting is aimed at refocusing members of the partnership on prevention, coordination of care, health maintenance and avoidance of complications, and reducing overutilization of modalities such as imaging and unnecessary hospitalizations or surgeries.

If the vision can be achieved, it will depend on partnerships with providers—in some cases, very close partnerships.

CareMore is one successful such vision. Now a subsidiary of Anthem, it started out as an elder-focused physician practice in Southern California that, over time, morphed into a health plan and delivery system serving seniors based on care protocols initially piloted at the physician practice, says Sachin H. Jain, MD, the division's chief medical officer.

"This is an organization that can model the future of healthcare," says Jain, who first heard of CareMore when he was with the Centers for Medicare & Medicaid Services, helping launch the Center for Medicare & Medicaid Innovation. Jain, who served as a senior advisor to the administrator of CMS during the first Obama administration, has also been a special assistant to the national coordinator at the Office of the National Coordinator for Health Information Technology, chief medical information and innovation officer at Merck, and practicing physician at the VA Boston Healthcare System prior to joining CareMore in January.

So given his background, what's he doing at a small, albeit innovative, California health plan for seniors? One reason: There was plenty of buzz about CareMore at CMS while he was there, Jain says.

"They built programs with breathtaking clinical outcomes and cost results," he says. "Four or five years later when I got a phone call asking if I would consider coming out to California, I said heck no … I'm an East Coast guy. But when a mutual friend said he was calling about CareMore, I told him, 'That's a different story.' "

Philip Betbeze is the senior leadership editor at HealthLeaders.

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