Profitable Care Management: Wedging Out Complex Members to Rein In Costs

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Healthcare payers have found themselves at a critical point. Rising healthcare prices, an aging population, and a rapid increase in costly complex and chronic diseases are driving up healthcare expenditures, expected to make up almost 20% of the U.S. economy by 2027. These same drivers are also shifting the balance of resources organizations must employ for care management, disease management, managing transitions in care, and care gap interventions.

Struggling to Navigate Needs

Over the past decade, many in the industry responded to the need for improved care management workflows with the introduction of large-scale, enterprise-wide technology that coupled care and disease management with utilization management (UM) functions for all of their populations. Today, healthcare stakeholders are finding that broad, traditional approaches to care management are not designed for the segmented needs of complex, high-cost populations. Although UM should be a part of an overall strategy, it has proven ineffective at significant cost reductions when it comes to specifically addressing the needs of the small percentage of populations that represent the heaviest utilizers of care.

For a growing number of healthcare organizations, the solution is applying a “wedge” strategy to address the needs of the 5% of members who incur approximately 50% of an organization’s total spend.

Recognizing an Opportunity

Healthcare payers have long recognized that members requiring critical, complex, and chronic care are the heaviest utilizers of medical services. The wedge strategy “carves out” these small groups of members and surrounds them with a comprehensive ecosystem tailored to their needs to achieve lower overall spending on care, improved care quality and outcomes, and enhanced member engagement and satisfaction. This ecosystem requires both systems and processes that enable organizations to proactively manage the delivery logistics involved with enhanced care.

The strategy relies upon a technology-enabled, member-centered solution that equips care managers with a full, whole-person view and the right toolset to eliminate the traditional boundaries between health siloes. It is especially effective at managing the unique needs of LTSS and other critical care populations because it considers both the clinical and social needs of members and aims to avoid the inefficient use of healthcare resources. Solutions like these enable the care team to identify non-medical (social) barriers, such as lack of access to nutritious food, inability to afford prescriptions, transportation limitations, and to take the necessary actions to reverse them.

Beyond technology, organizations must establish processes and workflows to test and identify programs that push the needle on outcomes for complex populations. For example, care managers should be trained on working outside of clinical spaces in order to identify and attend to non-clinical member needs like food insecurity. These tools must allow care managers to leapfrog both the legacy technology and the outdated processes that accompany it.

Leapfrogging Outdated Solutions

Modern platforms ensure that coordination and communication is fluid across the care continuum, enabling shared decision-making and ensuring access to appropriate medical attention from proper providers. While the primary care provider may be best positioned to coordinate care, make referrals, and schedule appointments, technology can keep care managers, caregivers, and the member seamlessly connected.

Involving members in their treatment allows them to bring their own needs and preferences into the conversation. Having a system that tracks these conversations and makes them easily accessible to all parties creates transparency and an opportunity for goal-setting with the member, coming closer to achieving an optimal level of member engagement.

These platforms are also more flexible than their legacy counterparts, adjusting to program changes and streamlining the updates or enhancements necessary to keep pace with the evolving and expanding market and related policies and regulations.

A Winning Strategy

Our latest white paper outlines how organizations can use the “wedge strategy” to get ahead of the urgent need to rein in the high costs of caring for complex and critical populations. Download the white paper to learn how one of the nation’s fastest-growing health plans is discovering the benefits of seamlessly layering a care management platform onto its existing legacy system. By optimizing utilization of healthcare services, the plan is driving down costs and improving health outcomes through early interventions and better management of chronic illnesses.

This article was created in collaboration with the sponsoring company and our sales and marketing team. The editorial team does not contribute.