Nearly a year ago, I wrote about Curt. He’s the vice president of human resources for a Fortune 500 company with more than $10 billion in sales, 150 customers and 15,000 employees. As you may recall, he spent 20 minutes on our Theon® advanced analytics platform and found actionable information to save more than $500,000 on employee medical costs while also improving employee health. His findings included:
- More than $500,000 in out-of-network utilization prime for possible redirection to in-network services and/or network expansion opportunities,
- 68 employees who visited the emergency department in the past year but not their primary care physician,
- 200+ employees with high-risk conditions who had not seen their primary care physician in the past 12 months for follow up and case management
- More than $39,000 in retail prescription refill costs that could be redirected to lower-cost, mail-order channels,
- 240+ employees taking brand name prescriptions that could switch to a generic and reduce medication costs,
- More than 500 employees who are pre-diabetic, and
- More than 10,000 employees with open care opportunities such as mammograms and colonoscopies – essential preventive services that may help prevent future high-cost conditions
As the one who is ultimately responsible for controlling his company’s health costs and improving overall employee health, Curt has become increasingly focused on the care being provided to employees who are considered high-risk – those employees who already have a diagnosis and are incurring significant medical costs – and especially those whose risk score is rising. Increasingly, predictive analytical models, like those at the heart of our Theon® platform, are able to successfully identify which employees are likely to become sick in the next 12 to 24 months. Health plans can then direct care management resources to those employees to prevent chronic illness and other expensive medical conditions.
Using the Theon® analytics platform, Curt identified a number of employee cohorts with rising-risk, including:
- More than 500 employees who are pre-diabetic
- 35 percent with a clinical marker for heart vessel disease
- 27 percent with a clinical marker for high blood pressure
- 27 percent with a clinical marker for high cholesterol
- 18 percent with a clinical marker for obesity
- 26 percent with two or more clinical markers
Armed with these numbers, Curt held a number of conversations with the four health plans his company was using. He asked each of the four plans to design a comprehensive health and wellness program with nutrition, physical activity, weight management and tobacco cessation components and specific engagement goals. He also wanted each plan to detail how they worked with network providers to measure, monitor and mitigate clinical markers.
Curt found the four plans quite illuminating. He always suspected the health outcomes and costs were better for providers in value-based care relationships and accountable care organizations (ACOs), and now he had compelling evidence.
One of the health plans showed him the results for his employees in fee-for-service arrangements compared to those attributed to value-based care providers. In short, there were significant quality and utilization improvements, especially for the hundreds of employees who participate in this health plan’s value-based care arrangements.
In the case of rising-risk employees, performance on HEDIS® measures is one suitable proxy for care management intervention. Another is risk score along with changes in risk score as the result of a health plan’s care management programs, something Curt has asked his health plans to document and ultimately to connect with performance guarantees.
These results combined with the number of rising-risk employees led Curt to reduce the number of health plans to the two who had significant value-based care arrangements. He also came to believe that tighter integration and collaboration between his employer, the two remaining health plans, and the plans’ provider networks would better serve his employees, especially those with clinical markers for disease. That’s why Curt decided to embark on a path towards the implementation of a value-based network for all of his employees, a plan he hopes will come to fruition beginning in January 2018.
*Curt’s experience is an illustrative example based upon the actual experience of a Geneia client. This information is provided for illustrative purposes only. Curt is fictional and not intended to represent any specific person. Any direct similarities to any real person are purely coincidental and unintentional.
 HEDIS® (Healthcare Effectiveness Data and Information Set is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.