Improving plan performance with connected care coordination

In a rapidly evolving marketplace, health plans continue to seek out new strategies for improving overall plan performance. According to the Journal of the American Medical Association (JAMA), waste attributes for up to $935 billion each year with failure of care coordination accounting for up to $78.2 billion.1 Failures in care coordination can include conflicting and duplicative testing, use of high-cost services when lower-cost, clinically appropriate services are available, and avoidable hospital admissions and readmissions. Most of these costs trickle down to payers and their members. With up to a third of medical costs attributed to waste, health plans are increasingly turning to technology that better connects all those in the delivery of care.

Many of the challenges in coordinating care can be eased through better collaboration, specifically tools and systems that connect payers and providers and enable them to share information – and, in turn, ensure members are guided to appropriate care while reducing the likelihood of costly, adverse clinical events (e.g., hospitalizations).

Here are three ways a health plan can use an integrated care network platform to significantly improve collaboration and outcomes:

1. Improve data sharing with smart notifications
   Smart, actionable, real-time notifications deliver essential data to physicians at the point of care, empowering them with a more holistic view of the member. For example, these notifications can tell an emergency department (ED) physician that their patient has a history of frequent ED visits or has specific behavioral health needs. With these insights — including clinical and financial information that resides within a payer’s database — physicians can quickly identify potential problems (e.g., chronic condition), while reducing the need for services that provide little to no benefit for the member.
   
   
2. Target at-risk members with timely education
   The ability to identify risks quickly and minimize guesswork is key to influencing clinical outcomes. That’s because high-risk members, often a small percentage of a plan’s member population with two or more chronic illnesses, can drive the largest share of healthcare spending2. Without timely information, payers miss critical opportunities to intervene and engage with members. For example, knowing a member’s risk level for developing heart disease or diabetes can influence coverage decision regarding preventive screenings. Or, knowing that 50 percent of patients under 50 are at a higher-than-average risk of certain cancers can influence payer policies around preventive screenings and treatment – and ultimately, prevent the need for higher-cost treatments down the line.
   
   
3. Manage multiple population health initiatives and risk with greater insights
   As payer-provider partnerships, such as accountable care organizations (ACOs) increase, the ability to track, monitor and plan care is paramount. Care management technologies support payers’ efforts in managing chronic disease, promoting wellness, and initiating lifestyle programs for weight loss or smoking cessation. Technology networks that synthesize data across multiple platforms can help payers get a clearer picture of the long-term challenges and social determinants of health their members face, as well as the opportunities to improve member engagement or gauge the success of ongoing health initiatives.

Armed with these insights, payers and providers can engage in more meaningful dialogue and work more collaboratively to improve care, decrease costs, and reduce waste, a cornerstone of value-based care. When payers have more granular insights into burgeoning health risks, and real-time visibility into population health trends, they can do a better job of monitoring risk-adjusted expenses, reigning in unnecessary healthcare spending and redirecting their limited resources to more proactive and preventive approaches.