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Health Risk Identification for Health Plans & Payers in Value-based Care

In healthcare, the transition to value-based care has been accelerating in recent years, driven by factors like the COVID-19 pandemic, technology adoption among providers, and rising costs of care in the U.S. Health plans occupy a pivotal role in helping to advance the shift to two-sided risk arrangements by helping providers to target engagement and proactive interventions on members who will benefit most. In this second blog of our series, we will focus on how member health risk identification can help reduce total cost of care while improving health outcomes.

Identifying Member Health Risks

Managing the cost and care associated with chronic conditions remain a top priority for health plans. According to the Centers for Disease Control and Prevention (CDC), 90 percent of the $3.8 trillion spent annually in the U.S. is for individuals with chronic conditions and mental health conditions. In addition, more than 65 percent of non-dual Medicare beneficiaries live with two or more chronic conditions and are more likely to need emergent care.

Accordingly, the shift to value-based care is prompting payers to seek a more holistic view of the risk factors affecting their members. Knowing members’ likelihood of developing a chronic disease, such as diabetes and related complications, can create opportunities to engage earlier with those at greatest risk for disease progression, hospitalizations, higher costs, and adverse outcomes. Risks can be influenced by several factors, including:

  • Age and gender
  • Insurance type (public vs. private)
  • Environment
  • Overall health (BMI, tobacco use, history of cancer)
  • Social determinants of health (SDOH)
  • Behavioral health diagnoses
  • ED utilization patterns

Considering the soaring costs for managing chronic disease, payers must leverage better solutions to identify patients at higher risk of hospitalization and poor outcomes.

Data Technology for Risk Management

To effectively monitor groups or individuals across the care continuum, more data sharing and collaboration is needed between payers and providers. Specifically, what’s needed is technology that pulls together multiple sources of data to improve both risk stratification and risk adjustment, which captures the data needed to plan and care for an individual within the population.

With the use of smarter admission, discharge, transfer (ADT) notification platforms, which synthesize multiple risk factors and dispatch only the most critical notifications to the point of care, health plans and providers can partner to identify, stratify, and adjust risk — which, in turn, can improve engagement, member services and, ultimately, clinical and financial outcomes. Health plans should ensure their technology supports sharing smart ADT notifications for improved risk identification and stratification to target case management efforts on members who need it most. This supports health plans to be more successful at identifying members to understand who is at risk, why they’re at risk, and who can benefit from outreach for improved engagement, better care management, and reduced costs.

Want to learn more about how health plans and payers can support the transition to value-based care?

February 20, 2023