New Mexico Voices: Medical management practices and measurable results

Dr. Mark Epstein
True Health New Mexico
Dr. Mark Epstein

At this year’s legislative session, NM Representative Deborah Armstrong sponsored House Memorial 29 to set up a healthcare cost, quality, and coordination commission. True Health New Mexico supported the memorial, which passed, in the hopes it will lead to cost containment and transparency. 

True Health New Mexico’s medical management team, formerly the medical management team at New Mexico Health Connections and now providing services for both companies, is seeing measurable results in our advanced practices that lead to cost containment and better outcomes.

Rep. Armstrong’s memorial brought to light the areas in which consumers can be more empowered and benefit from more clarity in how they seek care. It promises better care at lower costs, and that is good for the consumer, the healthcare provider, and the health plan. And, it helps our communities thrive.

When the Affordable Care Act was created, the guiding principle was that the tired, cynical business model of insurers running away from financial and health risks is no longer acceptable. The ACA challenged insurers to embrace their populations and manage their health.

NMHC and True Health New Mexico have done that by working closely with both the insureds and the medical providers early on and upstream in their care to keep insured members out of the hospital. When you manage health so that the patients have better outcomes and lower expenditures, it is good for everyone—aside from maybe a few hospitals who would be disappointed from a business perspective to have fewer sick people coming through their doors.  

Our team has created an advanced analytic system that uses both health plan claims data, combined with New Mexico Health Information Exchange data, to identify and stratify members who are at risk and intervene before preventable health issues occur. For example, we connect with people who, sometimes despite best efforts, simply do not refill their chronic medication prescriptions. We also connect members with primary care physicians when the need is identified, through member outreach driven by advanced analytics.

We have a robust team of case managers and case coordinators, and we are invested in medical management personnel beyond what a standard health plan would do. We aren’t shy about reaching out to the providers and helping them optimize care and remove barriers for their patients, as well. We regularly have peer-to-peer conversations to facilitate highly coordinated and individually customized care.

What we find is that this level of high touch leads to a reduced need for more expensive, downstream care.

And the results speak for themselves:

• NMHC members’ historical hospital admission rate runs 41-43 admissions per 1,000 members per year—significantly below both the “well-managed” mark of 50 per 1,000 and the New Mexico commercial average of 55 per 1,000. 

• Our 30-day “all-cause” readmission rate has historically run between 4.5% and 6%, again well below national and local benchmarks, which run from 9-12% for similar populations.

Our successes in consumer empowerment showcase the ways in which Memorial 29 can help all New Mexicans. The House Memorial stated the need to set up the independent commission because “healthcare costs are consuming an increasing percentage of the New Mexico state budget, which necessitates that the state seek ways to manage healthcare costs without causing widespread disruption.” With the passage of the memorial, the state is shining a light on the need for cost management and transparency, while providing excellent care for New Mexicans, and we applaud our lawmakers for making a positive change for healthcare in New Mexico. 

Let’s hope with these new initiatives, New Mexico will lead the nation in more effective medical management that benefits everyone.

Dr. Mark Epstein is chief medical officer of True Health New Mexico.