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Health Plans – Are you at Risk?

If you’re a Health Plan that doesn’t periodically “calculate” and assign risk to members, you’ve put yourself into a tight spot.  This is a foundational activity, which drives care management and planning for your member’s future utilization.  For capitated or fully insured offerings, this is a critical step in rate setting/premium determination.  For self-insured plans, you can create value and goodwill by enabling your customer to adequately plan for next years spend.

You Need to get One

If your organization doesn’t currently utilize a risk methodology, I would suggest you add the effort to your prioritization list, placing it at the top.  Even for those that do calculate risk, but through a 3rd party, I would strongly suggest bringing the activity and, more importantly, the knowledge, under your roof.  There are a number of “systems” or methodologies in the marketplace, I’m partial to the Johns Hopkins Adjusted Clinical Groups® (ACG®) System.  Its member focused, can be used for events underway, is predictive and provides equal visibility to the healthy members.  As for input, the mechanism should intake paid medical and pharmacy claims.

Having a robust member risk mechanism in place can enable more than what I mentioned above.  Use of a risk mechanism today is typically specific to internal processes and employees, where each employee has been trained to react to/leverage an indicator or marker in a prescribed manner.  The innovative use cases, value-generating opportunities, are those that integrate the use of the risk system into stakeholder Self-Service and pro-active services.

Impact of Social Media and Mobility

Over the last decade, portals have enabled the extension or “exposure” of certain business processes to stakeholders for self-service.  Many seem to prefer helping themselves, providing the site is intuitive and easy to use.  More recently, the explosion of smart-phones/mobile technology has markedly driven the desire and demands for both this and information on ones self.  This preference, for indirect communication, can be effectively leveraged through the use of a risk system.

Portals and Apps can be dynamic, driven by the members risk profile.  Content and tools helpful to a diabetic could be seamlessly incorporated into the member’s experience.  If recent claims and prescriptions point to an escalation from a primary care setting to that of a specialist, a list of nearby providers could be “pushed” out to the member, along with information and services dynamically added to their site/app.  As events unfold for a member, a “fog of war” can engulf them.  Through this connected experience you have the opportunity to provide them a checklist, recommend dos and don’ts, a guide to care, again done dynamically.  Another example deals with duplicative activity. If a battery of blood tests was performed by the PCP, which the specialist will need, you can facilitate coordination of care by noting that need.  By noting such in the checklist, you can enable the member in managing the costs by making sure the specialist makes a request of the PCP.  Even better, this is where a PHR can come into play, automatically initiating the request to the PCP.  Some of the more robust risk systems will include indicators on care resource utilization and level of coordination amongst providers.

Benefits and Opportunities

As you think about it, the possibilities are endless for incorporating the results from a risk management system into self-service and pro-active stakeholder systems.  An important result of doing so changes the member’s experience from one of being a pinball amongst providers, to one of being in control and on a deliberate path to a positive outcome.  The financial impact on the Health Plan is equally positive, spending is as needed, early intervention can deflect certain members from an event, or at least reduce the severity, the individual and/or employer groups are satisfied with the plan services provided and you retain and grow your business.

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