In recent years there have been countless medical advances that have brought treatment to thousands of medical conditions.  We now have much greater insight into the appropriate care and treatment of individuals with far greater reach and positive medical outcomes.  As a society, we have become quite adept at treating a multitude of disease states, reducing both the cost associated with treatment and the ill effects on the individual.  However, through all of these advances, the primary focus from a medical perspective has been to treat the patient after a medical event, and after the associated expenses have been incurred by the underlying health plan. 

Medical Risk Management

Medical Risk Management is the practice of identifying, assessing and prioritizing the medical risk in a group prior to a medical event taking place in the life of one of the members.  Recent technological advances in data analytics coupled with 10+ years of clinical work in the field have enabled enormous strides in our ability to predict who the future high cost claimants will be with a high degree of accuracy.  With the right data, the right tools and the right clinical resources, we have three times the industry standard capability to predict medical risk.

The idea of predictive analytics is not new.  In fact, the medical industry, and many others – ever wonder how Google knows what you are searching for before you finish typing? – have been using analytics in the form of data algorithms for years.  In the health care space, data analytics has been used primarily by underwriters to estimate the future claims of a group, but only at the group level.  For example, if your plan experienced $X dollars in claims last year and included 3 cases of Y disease condition, the carrier would use an industry standard data analysis tool to estimate (or predict) what next year’s claims would be – and then set the premium at the appropriate level.   However, notice that the use for predictive modeling in this example is to estimate what the group’s claims will be - at the block level - and has nothing to do with individuals on the plan that may be about to get sick and don’t necessarily even know it.

We agree that to predict future claims cost, one must consider claims history.  But when only 40%, or thereabouts, of plan participants in any given year see a doctor or fill a prescription, it’s difficult to build a complete picture about where claims are likely to be headed.  In our Medical Risk Management service, we capture multiple data elements from different sources for each individual member of the group.  We employ a customized HRA (Health Risk Assessment), biometric screening, expanded vision exam, and combine it with past medical claims and Rx data to characterize each individual’s likely risk of a future medical episode requiring medical care. 

Intervention

Once we are able to identify near-term claimants, we utilize a well-respected team of clinicians to intervene and manage this population.  This group provides a unique clinical service to high-risk individuals and their families that other cost and care management providers do not effectively reach.  Their targeted clinical prevention service is designed to engage individuals and families who are in the top 5% of high cost/high risk population – a group that typically drives upwards of 60% of a plan’s total claims cost.

We offer the individuals and families the opportunity to build a trusting, long-term clinical relationship with a seasoned team of health professionals.  This confidential service is provided by highly skilled and experienced nurse practitioners and clinical pharmacists who interface with the patient and/or their family members primarily via telephone and email to provide this confidential service.  These clinicians support health decisions and answer questions each step of the way, putting families in control of their own health and thereby provide your employees with the guidance needed to navigate the much fractured health care system.

Large Case Management (LCM)

In recent years, the health care industry has emphasized Large Case Management (LCM) or Disease Management (DM) as cost control measures, where the planning and delivery of coordinated care are used to improve the continuity and quality of care in a situation of potentially catastrophic illness.  This approach also includes an upfront negotiation of the associated care expenses in an effort to minimize the cost to the plan and to the individual.  And while LCM is an important component of medical service delivery, its benefits are relatively small compared to a Medical Risk Management approach that identifies and intervenes prior to that catastrophic illness.

The net effect of utilizing Medical Risk Management is not necessarily the prevention of a future disease state.  But rather, the “claims curve” of a typical disease state can be dramatically  flattened or reduced if you are able to intervene before the disease state occurs, rather than after, as is the case with typical Large Case or Disease Management services. 

In other words, you may not be able to prevent someone from becoming a diabetic; but you can prevent that diabetic from also becoming an amputee if you are able to intervene before his or her disease gets out of control. 

Pharmacy Benefit Management (PBM)

A true Medical Risk Management program would not be complete if it ignored pharmacy benefit offerings.  Annual drug costs from a Pharmacy Benefit Manager (PBM) can run 18-20% of a typical health plan costs and rarely place their participants’ interest first.  A program called URx was created in July 2008 to offer a much better option.  URx has separated the functions of a PBM into stand-alone components and as such, maintains independent control over contracting decisions and benefit design.  The costs for individual medications are negotiated on a per-pill basis, instead of the typical discount approach, which often contains a nebulous “list” price as a starting point.  The use of a sophisticated, value-based formulary is employed to produce a ranking of all medications available under the plan.   This unique design allows the member and their prescribing clinician to make value-based decisions about their medications, which ultimately results in improved outcomes for participants and cost controls for plan sponsors.

Summary

The greatest fallacy of health care is believing that skyrocketing costs are driven by how sick and old your workforce has become and that better access to medical care will reduce costs and improve quality.  Actually, the majority of medical costs are driven by a small fraction of your workforce, and that group changes almost every quarter.  The biggest impact we can have on both our plan premiums and the health of our employees is the early identification of a potentially catastrophic medical episode and then to intervene with an application of appropriate care.  Medical Risk Management takes a plan sponsor from being a “consumer of health care” to being a “responsible manager of his or her medical plan”.