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Making Total Cost of Care Contracting Work

By Philip Betbeze  
   December 03, 2015

CareMore's clinical model, in its original form, divides its elderly patients into two groups: the frail and chronically ill, and the nonfrail. The key principles of success under this model require that integration and coordination of care for patients and sites of care is not voluntary—managing complexity requires constant knowledge of the condition and resources must be available to adequately intervene.

Adherence to those principles make it possible to take a model developed in Southern California for the frail elderly and adapt and modify it to serve Medicaid patients age 14 and older in Memphis, says Jain, as a new CareMore-led Medicaid program in partnership with fellow Anthem subsidiary Amerigroup being implemented there is proving, he says. In Memphis, the company has taken a population that many primary care physicians don't want. It has expanded hours of access and implemented close monitoring with patients, and provides assistance with things as seemingly mundane as patient transport issues. Of course those things cost money, and paying for them is nearly impossible with fee-for-service reimbursement, but for a capitated population, such investments pay off handsomely from both health and financial perspectives, Jain says.

"We're a delivery system first, and we're a model of paying for delivery second, which I frankly think is how care should be delivered," says Jain. "Most clinicians who come here, after having practiced in other environments, agree on that. And it's quite refreshing for people looking at it from the outside."

Other adaptations
Memphis is not CareMore's only foray outside its California beginnings. One way of adapting it for other geographies is through CareMore Inside, most visible in a new partnership with Emory Healthcare in Atlanta.

"Emory, a renowned academic medical center, is now building CareMore care centers, hiring CareMore-type clinicians to deliver the extensivist model of care and our chronic disease management programs regardless of the payer," Jain says.

None of this would be achievable under other forms of reimbursement, he says. Even the equations underpinning ACOs break down if one can't measure the cost of certain interventions and bill for it, he says. The CareMore model is not burdened with such strictures.

"We have a saying at CareMore: Capitation is freedom," says Jain. "It's true. In models like ours that pay for transportation or air conditioners, there's no payment code associated with those things in fee-for-service. We're launching programs that would be very difficult to launch under any other model. In our environment, where we're both the delivery system and the payer, it works."

Philip Betbeze is the senior leadership editor at HealthLeaders.


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