HFMA ANI 15: How risk stratification, care coordination helps lower costs for insurers

It pays for a health plan to identify at-risk individuals and intervene to keep them out of the hospital--both in terms of the organization's bottom line and for the overall health of its members, according to a summary of a presentation at this week's  Healthcare Financial Management Association's Annual National Institute in Orlando.

During the presentation, J. David Thompson, chief operating officer of Oklahoma-based HMO GlobalHealth, detailed how a program called Proactive Care Management saved his organization an estimated $10 million to $12 million during its first 18 months.

To execute the program, the company first stratified its members by clinical risk and cost by analyzing their claims data and electronic health records, Thompson said. Then it categorized these groups by geographic area and poverty level, and finally, combined all the data sets to highlight groups that would benefit the most from intervention.

Once it identified these individuals, GlobalHealth used case managers to help its most at-risk members understand their benefits, receive the correct medical supplies and manage their conditions. Interventions could be as simple as a case in which a registered nurse swapped out a diabetes patient's faulty blood sugar meter, Thompson said.

GlobalHealth also has reached out to healthcare organizations in its network to help with patients' case management and share in the savings, he added.

"As an HMO, our primary focus has always been on care coordination and helping manage the ultimate health outcomes of all of our members," Thompson said. "In our experience, if you focus on improving healthcare outcomes and controlling costs, you achieve the most significant results and contribute to improving the overall quality of life for your members." 

Other payers have seen similarly promising results from risk stratification techniques paired with member engagement tactics, FierceHealthPayer has reported. QualCare Alliance Networks Inc. Chief Medical Officer Christopher Valerian, for example, described during the Medical Informatics World conference in May how his Cigna-owned, New Jersey-based health plan used intervention plans to lower its per-member-per-month costs.

To learn more:
- read the presentation summary

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