Thoughts on Integrating Evidence Based Medicine into Care Management

Healthcare & Life Sciences

July 22, 2013

As payers and providers come under new pressure to reduce the cost of high quality care, the benefits of using evidence based protocols to plan and deliver care can be tremendous. Organizations that have effectively incorporated the latest evidence based medicine (EBM) into their care delivery report significant reductions in complications, decreased readmissions, and rising patient satisfaction levels. In addition, deploying an evidence based approach to managing care can be a source of competitive advantage for both payers and providers as they come under pressure to increase efficiency and reduce the variability of care delivered across the continuum.

While most payers and providers recognize the importance of evidence in driving high quality, cost appropriate care, only a minority have made significant inroads into solving the puzzle of embedding the latest evidence based protocols into clinicians' workflows. Having spoken to numerous payer and provider organizations on this topic over the past few years, here is a listing of best practices which we hope will be of use to provider organizations, but also of interest to commercial payers and other healthcare stakeholders as well.

1. Embrace the shift from utilization review to active care management using interdisciplinary 'huddles' based on EBM

As payers and providers explore new reimbursement methods such as prospective bundled payments, the nature of care management teams is changing. Utilization managers formerly spent the majority of their time doing retrospective or concurrent documentation for the purposes of limiting denials and maximizing fee-for-service reimbursements. Now, care managers must actively identify patients who present a potential financial risk to the institution under new reimbursement models (e.g. bundled payments), and seek ways to mitigate those risks through targeted interventions and care coordination without negatively impacting outcomes. The transition requires a shift in mindset and skillset as interactions with the broader clinical team, the patient, and providers across the continuum of care become increasingly important.

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