Defining the Business Case for Targeted Care Coordination


A white paper and series of briefs from Avalere Health produced with support from The SCAN Foundation explore the use of non-medical data to better coordinate care for high risk Medicare beneficiaries, which can lead to improvements in care while providing health plans a return on investment.

Date Updated: 09/30/2014

Until the passage of the Affordable Care Act (ACA), Medicare Fee-for-Service (FFS) providers had little incentive to coordinate or manage care for high-cost beneficiaries, much less understand the individual characteristics that likely drive high health care spending. Over the next decade, Medicare Advantage enrollment is expected to grow, Medicare FFS payments will increasingly be tied to value and quality, and providers will inevitably take on more risk to serve an older and likely more complex member population…

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The California Medicaid Research Institute (CAMRI) compiled a report that identifies Californians who receive home-and community-based support and what services they receive. The brief brings together available information spread across multiple state and federal data systems.

In this paper, the National Committee for Quality Assurance (NCQA) discusses prior integration efforts; introduces a model for integrated entities and a framework for assessing and promoting quality of integrated care; and explores the challenges to implementing and achieving the goals of person-centered, integrated care for Medicare-Medicaid beneficiaries. They use the word “framework” to describe the key concepts underlying the structure and process measures; it can also be expanded to include the content of performance measures as companions to the structure and process measures.

To succeed in this era of health system transformation, plans and providers bearing risk – in an accountable care organization (ACO) for example – will need strategies for managing a broad array of care needs for high-risk beneficiaries across multiple settings of care. Download this fact sheet to learn more.