One of the biggest challenges for health plans today, as well as the greatest opportunity to reduce costs, is population health management. Although the majority of plan members in the United States are healthy, it’s that 5 percent to 15 percent of the population with multiple medical conditions, particularly those with behavioral health issues, that account for a disproportionate amount of spend.
These complex cases come in a variety of forms.
Patients with terminal illnesses and their families have to be counseled on end-of-life options, such as hospice or palliative care-resources that are often underutilized. Although surveys continually show that the vast majority of people would prefer to die at home, most die in the hospital. This is a major disconnect that could be alleviated with more direct, honest communication to understand what the patient really wants. This intervention not only improves quality-of-life and reduces distress for patients and families, but the expanded use of hospice and palliative care has been proven to lower healthcare costs1.
Population health management also targets high-cost, high-risk members with multiple medical problems. By better understanding and addressing current and potential medical, behavioral, social and lifestyle barriers, plans and providers work more proactively to reduce the incidence of costly ER visits and repeat hospitalizations, and improve care quality.
In recent years, plans have begun to not only look at medical conditions, but also the social determinants of health when working with these high-risk patients. In short, the medical community is recognizing the fact that, if patients don’t have food, shelter or live in a safe environment, they’re not going to properly manage their medical needs. So, instead of just looking at who is missing appointments or not taking their prescribed medicine, plans are increasingly delving into those patients’ life circumstances to identify, and remedy, the root cause-which may come in the form of a hot meal or housing.
More progressive population health programs are also finding new ways to leverage predictive and prescriptive analytics to better manage their entire member base-not just those at high risk. This outreach could include educating healthy plan members who are overweight, smoke or have other unhealthy behaviors on the lifestyle changes they need to prevent heart conditions, diabetes and disease development down the road. They’re also working with their “no risk” population to ensure these individuals get their immunizations, physicals and maintain their healthy behaviors. Engaging with members while they’re still healthy can have a significant impact on long-term costs because, in many cases, they prevent, or at least deter, the development of chronic conditions in these individuals.
Accomplishing all of this is no small job.
These complex cases take a lot of time, effort and resources to manage. Although most health plans have clinicians handling the interventions, these resources are limited. Organizations not only have to identify which patients to target and determine the best way to engage with them, but work with the rest of the medical delivery system to create an interdisciplinary care team to ensure members receive the resources needed to take control of their health.
The ability to access and analyze plan data is critical to this process.
Plans need to be able to search their population data for triggers-high member spend, repeat inpatient admissions, and emergency room visits, health history, and pharmacy spend on drugs used to treat chronic diseases. With strong data management and analytics tools in place, plans can quickly identify the members who require active case management today, as well as pinpoint currently healthy members who could be at-risk in the future.
Just as important, plans can use analytics to determine which of those individuals are most likely to respond to these interventions, so they can target their clinical resources where they’ll have the greatest impact.
This is not to say that other patients will be ignored. But, those less likely to respond may get periodic phone calls, emails and literature, whereas those most likely to engage might be contacted more frequently, or include video chat or on-site visits with the more traditional contact methods.
Once the program is in place, plans should use their data to analyze the effectiveness of the intervention, so they can create a cycle of continual optimization.
For example, plans can look at the baseline population in terms of their costs per member per month (PMPM) before and after the intervention, and ascertain what is sustainable, factoring in all the necessary statistical models of regression to the mean. It’s important to continually measure the long-term effectiveness of the programs they’re putting in place, and track which types of interventions and outreach channels are the most successful. This ongoing data analysis gives health plans the insights they need to more effectively control healthcare costs and improve long-term outcomes for the patients they serve.
To learn more about how EXL can help your organization effectively use and analyze the data you have to reduce costs and improve outcomes, contact us.
Dr. Victor Collymore,
Chief Medical Officer