Definition of Serious and Complex Medical Conditions (1999) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-14
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The charge to the Institute of Medicine requested that a committee be established to respond to the following questions: 1. Should health plans be required to have a general policy for dealing with serious or complex medical conditions, or should HCFA provide more specific guidance as to the types of beneficiaries to be included in this requirement?
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As the committee began its deliberations about the charge and considered information from the literature review, workshop, and commissioned paper, it recognized a need to identify a patient population that would have diverse and complicated needs requiring a multidisciplinary, comprehensive care management approach to ensure the best possible medical, social, and mental health outcomes. The committee acknowledges that the potential universe of patients with such serious or complex medical conditions is likely to be very large.
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The committee believes that access to medical specialists is only one potential element of the broad strategies of care management these patients require. The committee does not feel that the narrow focus on "access to specialists" appropriately addresses the complexity of needs for patients with serious and complex medical conditions.
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As the science base is strengthened, so too will be the ability of HCFA and health plans to correctly identify patients with serious and complex medical conditions who would benefit from broad strategies of care management. Recognizing these limitations, the committee recommends that plans first focus their attentions on patient populations with conditions that are serious AND complex.
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Recommendation 2: The committee recommends that the Health Care Financing Administration should provide guidance to health plans to assist their efforts to identify patients with serious and complex medical conditions. Specifically, the committee recommends the following language be used to facilitate efforts of plans to identify their enrollees with "serious and complex conditions": "A serious and complex condition is one that is persistent and substantially disabling or life threatening that requires treatments and services across a variety of domains of care to ensure the best possible outcomes for each unique patient or member." The committee recognizes the importance at this time of providing health plans with guidance to facilitate operationalization of their own definitions of serious and complex medical conditions.
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As the science base is strengthened, so too will be the ability of HCFA and health plans to correctly identify patients with serious and complex medical conditions who would benefit from a broad care management strategy, including those with serious but not complex or complex but not serious conditions. Recommendation 3: The committee recommends that health care plans develop a broad strategy for care management to enable pa tients and providers to achieve the best possible outcomes for each unique patient or member with a serious and complex medical condition.
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This is a tool for gathering information about the patient's medical, social, functional, and financial status that will be used to further determine his or her need for care management and the resources available to access the necessary services. Treatment or care planning is also recommended by the committee as an essential element of a care management strategy for patients with serious and complex medical conditions.
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These strategies should be consistent with the guidance outlined in Recommendation 2 to determine which patients meet a plan's threshold for serious and complex medical conditions and would benefit from a coordinated care management strategy. The committee recommends that health plans identify specific categories of patients or health conditions for which screening for the presence of serious and complex conditions should occur on a routine basis.
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There are several reasons why it is essential to the care of persons with serious and complex medical conditions that screening and selection of a plan's designated patient categories or conditions occurs on a routine basis. First, periodic screening allows the multidisciplinary care team to adjust the care management approach as patient needs change over time.
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The review process should be timely and should allow for both internal and independent external review. Recommendation 5: The committee recommends that health care plans develop a care management strategy that integrates the participation of all those involved in the care of the patient, including primary care physicians; medical and surgical specialists; nurses and nurse specialists; behavioral and mental health specialists; physical, occupational, and speech therapists; social workers; allied health professionals; and community-based service providers.
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The Health Care Financing Administration should establish a formal mechanism to evaluate a Medicare+Choice provider organization's program to monitor the outcomes of care for patients with serious and complex medical conditions. The committee recognizes that monitoring and evaluation programs will vary between health care plans but recommends that all programs include population-based monitoring of the outcomes of care for patients with serious and complex conditions, as well as individual case monitoring, assessment of provider interventions, and evaluation of best practices of care.
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This is primarily due to the fact that the committee lacked sufficient information and time to conduct informed deliberations about the implications of alternative definitions for serious and complex medical conditions for Medicaid and commercial programs, especially when applied to Medicare beneficiaries who are dual eligible. The committee strongly recommends that HCFA, in collaboration with Medicare and Medicaid provider plans, establish this as a research priority.
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This should be a priority area for collaborative research on policy issues to ensure continuous improvements in the care of populations with serious and complex medical conditions covered by Medicaid and fee-for-service Medicare plans. · Consumer Education and Participation.
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Thus, the committee urges HCFA, health care plans, and consumer groups to view this report, and especially its conclusions and recommendations, as first steps in the effort to address the unique and complicated needs of persons with serious and complex medical conditions and to ensure that they receive the most costeffective and best-quality care. The work of this committee is intended to support and provide direction for future work to be conducted by HCFA, in collaboration with all types of health care plans and consumer organizations, to design innovative strategies to ensure adequate reimbursement, access to broad care management, and the highest possible quality of treatment services required by patients with serious and complex medical conditions.
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