Taking a Longer-Term View of Investing in Preventive Care

Mary Bacaj, president of value-based care at Conifer Health Solutions, recently spoke with Healthcare Innovation about misconceptions around preventive care. She argues that self-insured employers should take a multi-year approach to assessing ROI rather than taking a single-year snapshot. 

Healthcare Innovation: Could you just start by describing your role at Conifer? The company has revenue cycle management and population health management arms, right? Can you talk about what you're involved with? 

Bacaj: Conifer is a partner for health systems, physician groups, and employers in the care they deliver and are responsible for. I run our value-based care business. We work with self-insured employers and Taft Hartley funds, which are the benefits armed of unions, to help them understand what's happening within their population, and reach out to those members who look like they could use support and give them one-on-one support to help them navigate both the utilization of their healthcare benefits. 

HCI: Does that also involve creating pay-for-performance programs for physician groups who are contracting with those employers? 

Bacaj: We do support physician groups that are on some sort of pay-for-performance type contracting model. But in those situations, we work with the physician groups and the health plans directly, versus doing it on behalf of self-insured employers and unions.

HCI: There was some news recently about Conifer — that CommonSpirit Health was selling its stake in Conifer back to Tenet Healthcare. Will that affect anything about what your group does? 

Bacaj: No, the announcement doesn't impact our population health business. We continue to focus on the services we deliver for our clients.

HCI: You wrote something recently making the case that in the face of rising costs, employer-sponsored plans might be skeptical of preventive health management solutions because they could drive higher utilization in the short term, but you say that reflects a misunderstanding of how preventive care works and where you see the payoff. Can you talk about that a little bit?

Bacaj: I think everybody inherently wants people to get the preventive services. You want to do right by the population you're insuring. When you look at the claims details, there’s a bunch of people who don't get care in any population. Those individuals — anywhere from 25 to 45% of a population — we call “no known risk,” and a good portion of those people have no claims. They’re not utilizing the healthcare system as a whole. So when you start trying to have those individuals engage in the healthcare system, you have a cost increase to begin with, because they're using services. Often, if they haven't gone to the doctor in 10 to 20 years, there are likely some hidden conditions that they haven't been treating. And even if they're healthy, there are likely a number of tests that they haven't had as well. So there's an initial increase in cost to ensure that the individual gets all of their preventative services — their mammogram, colonoscopy, blood work.

In good cases, the person is healthy and nothing is found. Unfortunately, in a good portion of cases, with someone who hasn't engaged with the healthcare system in 20 years, you find some underlying conditions that need to be treated. So then there's the treatment of those conditions and moving them from what we call an unmanaged state to a managed state. The individual has to see the doctor more often, has to be put on prescriptions, and so your costs increase from there.

HCI: So one of these self-insured employers might launch a preventive care management program, then see their costs are going way up and freak out about that. But you're saying that perhaps they're looking at the wrong metrics and they need to take the longer view?

Bacaj: Correct. Because that should over time pay off in cost avoidance as that person is getting the care they need for the condition they have. What could have evolved into a really high-cost case because something wasn't caught and wasn't managed, now you have a lower cost for that individual as their care is managed.

HCI: You’ve made a distinction between preventive care management and reactive cost control, which included things like prior authorization and working to make it more difficult to get care….

Bacaj: Prior authorization serves an important function in the healthcare industry, in terms of ensuring that the care people are getting is appropriate. It does take time and money to go get care, so you want to make sure that there's not waste in the system, right? There is a role for prior authorization, but that can't be the only lever. Another is ensuring that there are programs in place for care management to reach out to those individuals who are kind of floating through the healthcare system to make sure they are aware of the preventative services they should be getting, and getting those people engaged early, versus waiting 10 to 15 years down the line.

HCI: Getting back to the ROI question, are there other things you can be measuring in terms of cost avoidance? 

Bacaj: Yes, I think in in the short term there are some behaviors that you can see quicker impact on. We often find that some individuals are over-utilizing the ER from a care perspective, so that has an ROI in terms of shifting them to getting a primary care physician that they trust, and using that arm instead. Similarly for people who are in the hospital, making sure  that their transition to home goes well, and they get all of the services that they need. 

Unfortunately, because of the way our healthcare system is set up, during those transitions there are so many different organizations involved. We see often that there's a ball dropped somewhere after someone is discharged home from the hospital. For instance, they’re expecting oxygen to be delivered to their house, and it's not delivered for two or three days. That's a place where by helping early in the process there's a faster return on investment. 

There also are longer-term returns that can be measured in terms of movement to lower risk. If you think about a diabetic who has a high A1c and as they lose weight, they're monitoring their blood sugar, they change their diet. That may take a year or two before a diabetic is really in control of their diabetes. The return on that may be 2, 3, or 4, years out as they control their diabetes. That has some cost avoidance in terms of what would have happened had that individual continued on the path that they were on. 

There are other things that are even harder to measure, like productivity. Since we're talking about employers, the No. 1 goal is that people are showing up to work and they're being productive. That productivity can be lost due to health conditions and family health issues. If someone in your family has cancer, you can still go to work and be productive. But there is a mental mind share that it takes if a family member is going through cancer treatment, and therefore some productivity decline can be seen there. By having a care manager help them with that, it relieves some of that pressure, so that the employee can continue to be productive at work.

HCI: You make the case that a care manager can play the role of a benefits quarterback. And that's kind of what you were just talking about — when someone's in that transition of care and there are services coming from a lot of different companies, the beneficiary might not know all the benefits that are part of their plan. So it's nice to have somebody quarterbacking that for them and make sure that they're getting the services they're entitled to in a timely fashion.

Bacaj: Yes, very much. If you think about your healthcare benefits, some of the programs an employer may be paying for on a per-member per-month basis whether they're used or not. So utilizing those benefits may not actually cost any more to the employer. 

We also find that for people going through healthcare situations, it's a complex time, and they forget things. They may get home and not remember exactly what their doctor told them to do. So that quarterback can look at the doctor's notes, and serve as a reference for that individual to help them navigate the care that they have.

HCI: Most solutions we hear about now have AI and machine learning involved. So is there an element of that in your approach? Is there another aspect that requires human touch and interaction with people?

Bacaj: There's so much talk about AI everywhere, and there's definitely a place for it. We have a proprietary risk stratification that we do. We built machine learning into that — enhancing the models of predicting how much they're going to spend, so that that can be more specific with all of the data we have.

But the majority of what we do is really person by person, building trust with the individual and then helping them with their specific situation. Do some of the technology solutions out there have benefits? They definitely do. From our perspective healthcare is so complex, and a majority of the high-risk individuals have multiple conditions that they're dealing with, so that individual-to-individual relationship is really needed in order to get the behavior change that is needed, as well as really giving the person the support that they need.

HCI: Are there some other issues facing these self-employed insurers or union plans that are top of mind right now? For instance, what about the whole GLP-1 issue? There is an example where the cost may be high upfront and the benefits may be a few years out. 

Bacaj: Prescription drug costs as a whole are top of mind for a lot of self-insured employers and unions. Prescription drug costs are increasing faster than the rest of the costs that they're responsible for as a plan, and that's due to a number of different things. GLP-1s is one of them, but also just specialty drug costs and the cost of new specialty drugs. There’s a lot of conversation about PBM reform, but from an individual employer perspective, they can't do much on that. But what do they think about is contracting with PBMs for their specific plan and ensuring that they're managing those costs. 

I think we've seen a number of different approaches to GLP-1s. Some people jumped head first into it, saying we're going to cover GLP-1s for everybody, except for vanity reasons. In those cases, we've seen the GLP-1 costs expand dramatically. That has led to those organizations looking to pull back because the cost increases were unsustainable from their perspective. Others we've seen are taking a more measured approach. Some say just for diabetes in certain circumstances, and then it is still a big cost driver, but I think in most cases it hasn’t been long enough to see if there is ROI from them. According to the pharmaceutical industry, there should be an ROI there. From an individual employer perspective, most of them haven't been covering them long enough to see that curve yet.