The America’s Health Insurance Plans (AHIP) 2017 meeting in Austin wrapped up earlier this month, with lots of discussion about population health management – and a special focus throughout on social determinants of health. That focus (which you may or may not find surprising) reflects a broader trend in health plan management involving high-cost, complex consumers.
Since the widespread adoption of parity and the elimination of pre-existing condition clauses and lifetime plan limits, the focus on population health management has shifted to that group, often referred to as “superutilizers” (see No System Too Big? No Niche Too Small? Strategy Challenges Ahead and Looking Beyond The Superutilizer Umbrella). What has become apparent is that when there are comorbid behavioral health and medical conditions, the “big ticket” items are the medical conditions.
The question for health plan managers is – how do you retool case management, care management, and utilization management processes to best address this complex consumer population – and how to do it cost-effectively? The answer is the advanced use of applied analytics. That topic was the focus of the presentation, “Advancing Clinical Management Strategies by Integrating Behavioral and Physical Health Data,” with Debra Smyers, Senior Vice President of Medical Management of Sunshine Health and Candace Saldarini, MD, the Medical Director of ODH, Inc.
During the session we discussed the interactive, structured process of building a member dataset that goes beyond claims and using that dataset to create actionable insights for care management and utilization management teams. As Dr. Saldarini pointed out, there is a lot of data – it is just not integrated or organized to produce useful insights for care management.
Debra Smyers described how Sunshine Health puts advanced analytics to work. She outlined how they build profiles of segments of their member population – and use that segmentation to build action plans for care managers. “Our care management team can only take a thousand actions a day,” she said. “The question is, what are the right actions?”
This health plan’s goal in the use of advanced analytics in care management is to identify the right consumers where case manager action can have a positive effect on both health outcomes and cost. At Sunshine Health, case managers have the benefit of advanced analytics providing them with a list of the most important actions they can take that day to improve quality and cost. And, utilization managers now have a real-time “complete picture” of every member’s history and health status to assist in their discussions with health professionals. On the return-on-investment (ROI) front, Sunshine Health is creating a process of rolling ROI analyses of their case management and utilization management activities using these advanced analytics.
One interesting takeaway for me from the discussion was why claims data is not enough. Ms. Smyers talked about how slow the behavioral health provider organizations and professionals are to submit claims, which impedes their care management. Their solution is to incorporate information about outpatient authorizations and HIE-derived emergency room information into the mix. This is an example of how health plans are using technology to reshape member health management processes to address complex consumers. I’m sure we’ll see more of this approach in the years ahead.
For more stories on the use of advanced analytics in care management, check out Hot Spotting, Medical Neighborhoods & New Business Opportunities and Using Pharmacy Data Analytics To Improve Medical Home Performance.