Payers can use a combination of claims, lab and pharmacy data to apply risk stratification algorithms to their member populations, but they won't start to see savings until they appropriately engage with members.
At the Medical Informatics World conference in Boston, Christopher Valerian, chief medical officer of QualCare Alliance Networks Inc., described how QANI used risk stratification information to develop intervention plans, share them with healthcare providers and reduce per-member per-month (PMPM) costs for the members with whom the plan had actively engaged.
QANI, a New Jersey-based health plan recently acquired by Cigna, first stratified its member base as 61 percent low-risk, 32 percent medium-risk and 7 percent high-risk. From there, the health plan layered its health risk assessment (HRA) data on top of the risk model. Tellingly, Valerian said, the negative health factors most likely mentioned by those in the high-risk category were not necessarily medical--namely, lack of physical activity, job dissatisfaction and life dissatisfaction.
Next, QANI crafted intervention plans. In some cases, the insurer pushed claims data directly into providers' electronic health record (EHR) systems, providing insight such as a patients' other physicians. In other cases, QANI would push information about preventive screenings or utilization rates. Population health management efforts work best when payers and providers collaborate and share data, FierceHealthPayer previously reported.
For high-risk members, this amounted to chronic condition management, complete with individual care plans and care gap interventions. Here, Valerian said, cost mitigation was the main goal. For low-risk members, QANI sought reasons to engage with members; otherwise, he said, the health plan would know nothing about its healthy members.
Moderate-risk members represented the biggest opportunity, Valerian said. They may have one or two chronic conditions--and, through a variety of initiatives, from behavior modification to health coaching to care coordination, they can effectively manage these conditions.
In a 2013 pilot program, PMPM costs decreased 2.2 percent for members in all three risk stratifications when QANI was able to actively engage with those members, Valerian said. For non-engaged members, PMPM costs increased 14 percent.
The engagement program has succeeded to the point that, as of 2015, QANI applies it across its membership base. "This is how we now do business as a health plan," Valerian said.