Much of the rhetoric associated with reducing healthcare costs rightfully focuses on the top of the proverbial pyramid--patients with multiple comorbidities who make up 1 percent of the population but, by various estimates, account for 20 percent of healthcare costs.
However, it's arguably just as important to address the needs of the patients one level down on the pyramid: Patients with a single chronic condition that, left untreated or even unaddressed, could lead to another chronic condition, making his or her care increasingly complex and costly.
For the last eight years, the Government Employees Health Association (GEHA) has used predictive modeling tools for the purpose of risk stratification, Kathy Ross, vice president of clinical operations and chief health officer with GEHA, said in an exclusive interview with FierceHealthPayer at the recent America's Health Insurance Plans AHIP Institute.
From there, Ross said, GEHA aimed to address the health needs of the 85,000 moderate-risk members in its population of roughly 1 million covered lives. A similar risk stratification effort by the QualCare Alliance Networks divided the patient population into 62 percent low-risk, 31 percent moderate-risk and 7 percent high-risk.
It wasn't enough to use the interventions that engaged the low-risk population, Ross said, as that consisted mainly of care reminders. On the other hand, it was too much to give those patients the same type of comprehensive care management plan that high-risk patients received.
Yes, moderate-risk patients typically have one chronic condition, and risk developing another, but they don't think of themselves that way, Ross said. They don't want to be treated like really sick people, according to Ross. "Don't have a nurse call, or else that will validate that I'm sick."
Building on the chronic care management philosophy of Stanford University School of Medicine professor Kate Lorig, GEHA turned to peer connections instead of nurse practitioners in its obesity management program, Ross said. These peers share recipes, exercises and weight-loss tips to help them bridge the gap between where they are and where they want to be.
"I believe that that is going to be a voice that they will listen to," she said.
The return on investment for the chronic care management program stems from the positive impact on consumer engagement. "If we can engage them, we're going to see improvements," Ross said. If patients comply with asthma treatments, or increase their hemoglobin levels, then they are less likely to end up in the emergency room and will prevent those additional chronic conditions.
"That engagement will translate into saved dollars and better outcomes and people who are on a motivated path to improve their lifestyle," Ross said.
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