Optimizing Care Management Through Whole-Person Care

Payer Readiness with Growing Medicare Advantage Populations

There is a new strategic agenda for healthcare payer operations. Market forces are converging from multiple directions, demanding a higher level of performance to achieve economies of scale and greater profitability.

Within the framework of value-based care, today’s health plans navigate an increasingly competitive playing field characterized by regulatory pressures and the need to improve population health for high-cost, high-risk patient groups. Optimal care management strategies that get out in front of patient health risks are now foundational to aligning with these movements and positioning for future sustainable success.

For instance, consider the evolving Medicare Advantage (MA) boom. Not only has enrollment tripled from 5.3 million in 2004 to 19 million in 2017, but the Congressional Budget Office projects 22 million enrollees by 2020 and a whopping 41 million by 2026.1

Recent changes to MA plans make them particularly attractive, which means that these trends will likely continue.2 For example, the Centers for Medicare and Medicaid Services (CMS) now allows members to add long-term care benefits, in-home support services for individuals with serious health conditions, short-term respite care, and adult day care services. Consequently, payers who work in the MA space will increasingly need resources to effectively manage a large population of aging members with more acute and chronic diseases, as well as specific social challenges.3

It’s just one reason payers need innovative tools that power forward-looking care management models and promote patient-centered care across the continuum. While data is their strongest ally in this quest, many payers’ strategies are informed by clinical and claims data only, limiting their ability to address the full spectrum of member needs. Care management must evolve to encompass the right technology and processes to proactively address a whole-person care strategy that considers the specific nuances and risks characteristic of today’s MA populations. It must also go beyond simply aggregating data; payers must proactively use data to inform proactive action that gets out in front of potential care gaps.

Whole-Person Care: Raising the Bar on Care Management

Payers overwhelmingly understand the relationship between population health strategies, data and better performance. A recent New England Journal of Medicine Catalyst report found that population health and clinical management are the top two analytics priorities for payers and providers, and hefty investments are underway into infrastructures that enable tracking of member activity across the continuum.

A growing body of evidence points to the effectiveness of leveraging analytics to improve patient outcomes.4 When payers can track member activity across multiple providers and clinics as part of a population health initiative, they have the data needed to proactively reach out to patients or predict future healthcare needs.

Yet, many strategies fall short because they fail to consider factors impacting member health outside of clinical and claims data. Social determinants of health (SDoH) are believed to impact 60% of a person’s health and are defined by Healthy People 2020 as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”5

The U.S. healthcare systems spends $1.7 trillion for 5% of the population with chronic diseases,6 mostly due to the SDoH. In addition, SDoH factors contribute to more than 50% of readmissions.7

Whole person care addresses the full patient picture including SDoH and aligns with current movements on the national stage to prioritize interventions related to patient’s unique social characteristics. Notably, U.S. Department of Health and Human Services Secretary Alex Azar said the department would expand Medicaid, Medicare, and MA benefits related to SDoH and specifically address aging populations’ issues.8

The reality is that many patients suffer with at least one SDoH challenge. In older adults, this is typically the availability of and access to community-based resources and transportation options. In addition, studies have shown that increased levels of social support with elderly populations are associated with a lower risk for physical disease, mental illness, and death.9 Another report points out that elderly and disabled patients have complex health needs, often impacted by multiple chronic conditions, cognitive disability, and social isolation, as well as the need for long-term care services and supports.10

Integrating Care Management for Better Outcomes

Whole-person care necessitates that payers are able to bring all data streams—clinical, behavioral, and social— related to patient health into a single view for streamlined, proactive care management. While health IT is an important enabler of this goal, few systems are designed to address SDoH at a high level.11

For example, one way that health plans must address SDoH for better outcomes in elderly patients is through transportation assistance. Care managers need efficient ways of identifying and accessing available services to ensure members are able to access to often overlooked activities, like doctors’ offices and pharmacy visits.

Solutions like VirtualHealth's HELIOS platform overcome these limitations by aggregating and analyzing multi-dimensional member data, including clinical information, behavioral assessments, risk algorithms, and SDoH, helping care managers optimize interventions based on a 360° view of individual members. This integrated approach ensures care managers can see all care gaps a patient may face and conduct proactive outreach before a condition exacerbates and requires a higher-cost intervention.

HELIOS provides a foundation for care managers at one state-run program to conduct 2,000 assessments and complete nearly 5,000 interactions with patients daily.

Specific to transportation, the solution is changing the paradigm through a module that enables care managers to schedule recurring trips for patients without leaving their daily platform. One managed health plan is using the platform to forecast transportation usage trends across months, time of day and geography to help its team optimize operations and predict expenditures. For example, the company can determine which patients are frequent transportation users, which can alert care managers to book multiple provider appointments for a member in one day versus multiple round-trips across several days.

To understand the clinical and cost potential of whole-person care, consider HELIOS’ impact on outcomes at New York City’s Services for the Under Served (SUS). A leading human services agency that provides $185 million in services to vulnerable populations, SUS conducted a study following deployment of the platform and its use to gain insight into developmentally disabled patient populations. Ultimately, the organization realized a 15 percent reduction in caregivers per case, a 70 percent reduction of challenging behaviors within the first six months, and a 30 percent reduction in the use of psychotropic medications.

Coordinated care that is built on a whole-person approach to care management is an essential part of redefining the future of healthcare. An integrated, patient-centered strategy recognizes the link between physical, behavioral, and social health and equips care teams with actionable insights into all risk factors, resulting in improved outcomes and lower costs.

VirtualHealth is uniquely positioned to help healthcare organization’s advance whole-person care through HELIOS—the first cloud-based, native platform in the care coordination space. Used by some of the nation’s most innovative, forward-thinking health plans, HELIOS provides care management teams the proactive insights needed to improve outcomes and lower the cost of care for millions of healthcare’s most vulnerable, highest-risk patient populations.

For more information on the HELIOS care management platform or to request a demo, connect with us.

  1. Silverstein J. 4 Reasons Why Onsite Primary Care is Mission-Critical for Senior Living. Senior Housing News.

    January 31, 2019.
  2. Roberts D. Changes to Medicare Advantage May Make Plans More Attractive. American Journal of Managed Care.

    February 20, 2019.
  3. Garza A. The Aging Population: The Increasing Effects on Health Care. Pharmacy Times.

    January 19, 2016.
  4. Kent J. Top 4 Big Data Analytics Strategies to Reduce Hospital Readmissions. Health IT Analytics.

    October 26, 2018.
  5. Social Determinants of Health. Office of Disease Prevention and Health Promotion. Health.gov.

  6. Sullivan T. Social determinants of health and the $1.7 trillion opportunity to slash spending. Healthcare IT News.

    October 9, 2017.
  7. Gooch K. Social determinants of health contributed to half of hospital readmissions, study finds. Becker’s Hospital Review.

    October 25, 2018
  8. https://www.ajmc.com/focus-of-the-week/azar-cmmi-will-get-more-involved-in-addressing-social-needs-driving-health-issues

  9. Joszt L. Azar: CMMI Will Get More Involved in Addressing Social Needs Driving Health Issues. American Journal of Managed Care.

    November 16, 2018.
  10. Thomas-Henkel C, Schulman M. (2017). Screening for social determinants of health in populations with complex needs: Implementation considerations. Center for Health Care Strategies, Inc

    October 2017.
  11. Goedert J. How HIT can impact use of social determinants of health. Health Data Management.

    November 14, 2017.