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Modern Care Management for Healthcare Payers


Care management is getting a lot more complicated. Chronic disease is the number one killer of Americans, while complexities brought on by comorbidities are a continuous burden on treatment and quality of life. Value-based care initiatives increase demands on payers and providers to balance care delivery, outcomes, and cost.

While most payers have developed programs to identify and support members with chronic disease, even the most advanced disease management programs miss opportunities available through insights into a more complete patient journey. This is especially true for payers establishing relationships with new members where pre-enrollment behaviors and healthcare histories are murky. 

What’s been missing is a proactive, data-enabled approach that supports the early identification of rising risk and gaps in care through deep insights into patient histories.

Unfortunately, many payers are working with fragmented and incomplete data that makes it difficult to predict and plan for health risks. While the missed opportunities have been significant in the past, they’re only going to grow as the complex healthcare landscape continues to evolve.

Payers can expect the pandemic to layer on an extra dimension to their existing disease management efforts – from deferred preventive care to major downstream impacts of COVID-19 and increased costs.

Payers’ Path to Complete Health Data

Payers play a crucial role in managing resources in a way that produces the best possible outcome, but to do that, they need to move beyond simply understanding the patient journey and push toward a goal of developing rich insights that are contextualized within the US population. These insights rely on timely, longitudinal data assets that illustrate patient behavior and experiences in detail.

Building a deep patient history means seeing not just a blood test, but also the diagnosis. It means identifying a condition that’s beginning to worsen five years earlier than current use of data allows today. It means working with SaaS partners who can deliver patient journey histories in minutes instead of relying on less efficient practices that can take months just to determine diagnosis. A deep history of the patient journey reaches forward to include emerging factors such as social determinants of health to identify propensity to change. Insights from the patient journey can also help to prioritize interventions more effectively, so expensive resources, such as RN outreach time, aren't misused contacting patients who are already highly likely to take action on their own.

Supporting Disease Management Programs

For an illustration, look at disease management in the Medicare Advantage (MA) space, where obtaining new member histories is particularly challenging, and compounded by complex, high-cost diseases.

To keep up with value-based care objectives, successful care management programs rely on early identification and action to manage chronic conditions. Program outcomes can hinge on early access to medical histories that enable timely intervention.

For example, when an MA program brings on a new patient with chronic kidney disease (CKD), the patient and program can immediately benefit from precision insights into the patient journey. By taking quick, deliberate action, the payer can reduce the odds the disease will progress to a far more costly and serious condition such as end-stage renal disease (ESRD). These insights also enable identification of the programs and processes that best meet patient needs, optimize adherence, and minimize gaps in care. In the past, payers have implemented these solutions with spotty information, effectively guesses, about their new members – often delaying identification of a patient with significant care management needs by months.

But the application extends further. Rich insights also provide answers to the question of what to do with high-prevalence diseases like hypertension and asthma. For example, nearly one out of every two Americans has hypertension. These patients have about 2.5 times more inpatient costs, twice the outpatient costs, and triple the prescription costs of other patients.

It is critical that payers today direct their resources to positively impact population health by identifying new opportunities to create programs that get ahead of the emerging needs of their members and patients.

Looking forward, payers who invest in this approach can reasonably expect to see reduced duplicative services, successful value-based care initiatives, and improved efficiency in wellness and prevention initiatives – objectives that rely on a comprehensive view of the patient journey and deep understanding of member histories to predict and manage likely conditions and challenges.

To learn more about how advanced data-driven technology can support the next phase of evolution of your disease management program, click here.

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