Payer Leans On Wellness, Care-management Program

Sept. 24, 2009

Using predictive modeling and stratification software, Highmark Blue Cross Blue Shield classifies covered members into one of 30 population segments.

Using predictive modeling and stratification software, Highmark Blue Cross Blue Shield classifies covered members into one of 30 population segments.

Historically, employers have looked to insurers to control healthcare expenses, notes Robert Muscalus, D.O. and senior medical director, at Highmark Blue Cross Blue Shield, by pursuing aggressive contracts with physicians and facilities, and enrolling individuals with severe conditions in care-management programs. “This has proven not to be an effective long-term solution, either clinically or financially,” he says. “It’s easy to identify people with chronic conditions like diabetes or congestive heart failure. However, a significant portion of a group may be at risk for chronic conditions – based upon factors like lifestyle choices or family histories. Some may already have these conditions, but may not know it.”

These individuals are likely to experience serious health issues in the future that impact both their quality of life and medical expenses. “It has become clear,” Muscalus says, “that it is more effective to engage individuals according to risk and not by diagnosis.”

The payer community, in particular, is driving the movement toward enhanced, cost-effective population health management. Pittsburgh-based Highmark, for instance, has implemented a program called Blues on Call Plus that is directed at members covered through employer-sponsored health plans. Distinct from the traditional Highmark insurance offerings, the program takes an approach to wellness and care management by applying technology to stratify risk, design interventions based on projected utilization, and calculate both clinical and financial return on investment (ROI).

On a monthly basis, Highmark analyzes the Blues On Call Plus population, sorting it according to claims and pharmacy data, as well as health risk assessments (HRA). Using predictive modeling and stratification software, Highmark classifies covered Blues on Call Plus members (comprising about 10 percent of the whole) into one of about 30 population segments. These are then grouped into seven broader health categories: intensive case management (severe illness); primary chronic conditions (e.g., heart disease, diabetes); targeted health conditions (e.g., chronic back pain); non-targeted health conditions (e.g., hypothyroidism); high-risk behaviors (e.g., smoking, obesity, family history); apparently well individuals (low-risk lifestyle behaviors, and or family history); and non-users (no appropriate claims, or health risk assessment data to assess health).

One client with 20,000 employees dispersed throughout the country in small pockets
had significant savings within the first 18 months of the program.

Every member is assigned a category; those with multiple conditions or risk factors will be placed with the segment representing the greatest risk and, therefore, highest potential cost, according to Kristen O’Donnell, consulting practice leader for Highmark’s personalized health management.

Customizable Programs Offered

Based on this data, Highmark works closely with employers to customize programs for employers to promote wellness and improved health status within any or all of these categories. For companies with centralized office locations, for instance, the program can modify cafeteria food choices, establish onsite wellness programs or deliver condition-specific information to employee desktops. For firms with a preponderance of remote or field staff, on the other hand, Blues on Call Plus can offer job site or at-home options.

The program relies heavily on actuarial science and information technology to identify areas of greatest opportunity for positive impact. According to Joli Studley, manager of clinical report development and evaluation, one client with 20,000 employees dispersed throughout the country in small pockets had significant savings within the first 18 months of the program. Relying on software developed through actuarial consulting services provided by SCIOinspire Corp., it “sliced and diced” data about the cohort, and designed a wellness program that could be implemented in rural areas across multiple time zones among an employee population with diverse understandings of wellness and care management. Within 18 months, the company realized significant cost savings, with a trend reduction of about 2.4 percent, increasing to 6.27 percent at the end of the second year.

Calculating ROI is no small task, admits Muscalus, but it is becoming increasingly important as employers and members demand reassurance that their insurance dollars are well spent. “Each group is different and the timeline of outcomes will vary based on several factors,” he explains.

Company A, for instance, may subscribe to Blues on Call Plus as its first-ever care-management program. Company B may have implemented such an effort three years earlier, but wants to upgrade its offering through Highmark.

“Company A will most likely see utilization and claims rise for the first year or two, as our staff encourages employees to undergo physicals and begin to take care of any conditions that are identified,” Muscalus says. “If employees at Company B already had worked with health coaches and participated in wellness programs, their ROI will come much more quickly.”

New Intelligence Incorporated

The ROI model the program utilizes relies on historical and projected per member/per month calculations. When launching the program, actuarial and data management experts review a full year of claims to establish a starting point. While this analysis provides a baseline, variables affect cost year-to-year – such as the employer’s turnover rate and aging of the workforce.

To project likely performance, personnel take into consideration members’ risk factors, percentage of insurance non-users and other factors. As the program progresses, real figures are verified and future modeling incorporates this new intelligence. Recently, one employer group began to see trending decrease by more than 9.94 percent and realized a cost savings of $3 million over the first two years of program implementation.

“However, we don’t limit our measures to encompass only financial results,” notes Studley. “We analyze the data to see if we are affecting clinical outcomes, as well. Are we improving non-user rates? Are we seeing an increase in the members who are receiving mammograms, and prostate and colorectal cancer screenings? “

She adds that success depends greatly on close collaboration between the employer and Highmark. “To truly engage members and involve them in significant ways, we have to promote the program heavily and reach out to employees on a regular basis. “

Blues on Call Plus staff likewise work closely with employers to ensure programs are tailored to the specific company. “One organization may have a high rate of employee turnover,” says Muscalus. “Another may keep employees long-term, up to retirement. The latter is more motivated to invest more heavily in efforts that promote lifetime health, like building a fitness center.”

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