Claims Management News

‘Data is Key’ to Cut Healthcare Spending, Boost Engagement

Patient engagement is vital in the search for lower healthcare spending and improved health outcomes.

By Vera Gruessner

A major goal among health payers today is to decrease continually rising healthcare spending. One way to do so is to identify patients who are at higher risk of deteriorating medical conditions and looking to engage with their provider to improve their health status.

Patient Engagement

These type of procedures can help payers reduce healthcare spending by creating a downward pressure on the number of emergency room visits and hospital admissions through preventive care.

Patient engagement is vital in the search for lower healthcare spending and improved health outcomes. Nonetheless, the question remains: how can health payers find the patients who are at higher risk of deteriorating and willing to engage with their providers?

In an exclusive interview, Pamela Coffey, Chief Clinical Officer at HealthSmart, attempts to answer that question.

HealthPayerIntelligence.com: How can health plans identify patients who are at highest risk of medical problems?

Pamela Coffey: “We engage or use the tool through LexisNexis called the Population Health Monitor. This is a predictive model tool that not only aggregates risk using episodes of treatment groupings but also the tool that will forecast risk. In our world, we are looking to identify those individuals who are at risk today. We also want to identify individuals or  members who are going to be at risk in the coming months.”

“Our strategy is in using the predictive model, what we’re able to do is provide in-depth analytical tools down to our clinician level. We have registered nurses and master-level registered dietitians who actually use this tool in their day-to-day work to identify those individuals with not only high risk but also with impactable risk.”

“We want to have the ability to go in and not only find the individuals at risk but stratify those down to a level of individuals who will actually benefit from our interactions, interventions, and engagement.”

HealthPayerIntelligence.com: What steps can health payers take to increase patient engagement?

Pamela Coffey: “What we do is we go through to identify where the pockets of risk are. We have a number of different programs that address different types of risk. That includes acute risk, chronic risk, and specialty risk. Those might be maternity cases that have high risk components to the pregnancy.”

“We also use a tool within the predictive modeling system called the Motivational Tool Index. What this does is it gives us an added boost when it comes to patient engagement because it allows us to filter through those individuals who have documented risk to also those who are most likely to engage and participate in managing their health.”

“In doing this, we have the ability to categorize and place these members into programs that will achieve the best outcome. The Motivational Index is the key contributor to identifying the members who are motivated to self-manage and are more likely to move into an area of compliance, which helps them take control of their health and makes them feel like they’re part of the solution.”

HealthPayerIntelligence.com: What tools or technologies should health plans utilize to engage patients and identify who needs greater medical attention?

Pamela Coffey: “I think the tools are key. The reason I say that is you can spend a lot of time scouring claims information to identify members with a particular diagnosis that  you’re focusing on - let’s say diabetes.”

When you have a predictive modeling tool with the ability to stratify the population not just with their combination of risk but also the stressor index to say that they are motivated to participate in their care plan, you have the ability to really build your pockets.”

“Out of the 5,000 people identified, where do I start? In the days of old, you used to go through and you’d try to be something to everyone. That just doesn’t work. It’s not financially feasible to do that.”

“What we’ve done is used the tool to go in and say, ‘Of this population, who is going to be the most responsive to us? Who is more likely to engage with us? Let’s focus there.’ That’s what we call our long-term strategy for those individuals with chronic disease.”

“If you have an acute situation, the sheer nature of that acute situation may render them unable to interact with you. You handle those individuals in a different manner. In our organization, we put them under case management. The tool actually helps you narrow down to the more successful population to engage.”

HealthPayerIntelligence.com: What advice would you offer to health insurers looking to reduce healthcare spending by decreasing emergency room visits and hospital stays?

Pamela Coffey: “To really get a handle on that, you have to identify why these services are being used. Oftentimes, it’s because of a lack of primary care in that healthcare scenario. My recommendation is that you have the data that let’s you identify what are the features and factors in that healthcare scenario that make them high risk. Data is key.”

“You need to identify what the cause of the emergency room use is or the hospitalization, which tends to be an exacerbation of a situation that if it had good, sound primary care to begin with, they would seek out the care of their primary care physician or their specialist rather than going to the emergency room or having their condition degrade to where a hospitalization is necessary.”

 

Dig Deeper:

Why Payers Need to Address Patient-Centered Medicine

Key Ways Blue Cross Blue Shield Raises its HEDIS Scores