How Can Health Plans Manage Risk Adjustment in a Post-Pandemic Healthcare Landscape?

  • octubre 11, 2022
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Deferred care has been an issue across the entire healthcare system since the COVID-19 pandemic began. For health plans, factors such as delays in care, uncertain reimbursement of new modalities of care, and limited access to large populations created a gap in properly assessing members’ risk scores.

The behavior of health plan members also changed drastically. Many Americans only sought out care in a true medical emergency. This changed how organizations track and manage real-time digital analytics to ensure an accurate view of subscriber populations.

To help health insurance companies navigate the many challenges in the new healthcare landscape, we have identified three specific strategies that will bolster their risk adjustment strategies. These will enable health plans to transform their methodologies of capturing appropriate risk scores through a digitally enabled, at-home experience with their benefits and adapt to other changes brought about by the pandemic and changing member behavior.

1. End-to-end digitization of real-time management for large populations through EDS systems

Historically, aligning consumer satisfaction with health plan interaction has been a challenge. Certain factors, such as the socioeconomic status, age, and living conditions of target populations, create opportunities for health plans to enhance engagement models through new reimbursement methodologies. The mix of leveraging digital functionality and prioritizing at-home care via mid-level support provides plans across the U.S. an opportunity to bridge the gap.

The backend integration and aggregation of data from separate sources will require strategic and operational investments from plans surrounding how organizations manage data and analytics. Dovetailing consumer experience, digital engagement, new care settings, functionality, and risk adjustment through transforming data and analytics infrastructure will effectively prioritize EDS investments.

2. Innovative and integrated HRA programs to capture risk early in the plan year

Health Risk Assessments (HRAs) can get people necessary care when it matters the most — before problems escalate. Around 65% of large employers offer an HRA, but simply offering one is not a cure-all. To make a meaningful impact, employers must ensure that employees fill out the HRA and follow up appropriately.

Conducting an HRA is an essential first step in controlling health costs. With fundamental information about the kinds of services or support different employees need, bigger problems can be avoided in the future. The ability to diagnose diseases and match patients with relevant and helpful programs is critical to getting people the right care. For instance, a stellar diabetes management program is ineffective if diabetic employees are not participating in it.

Savings estimates will vary, but successful examples of worksite health promotion programs featuring HRAs exist today. For example, Johnson & Johnson achieved savings of about $9-10 million per year primarily from reduced medical utilization ($3.96 million) and lower administration expenses ($5.22 million) after it started a company initiative to encourage the filling out of HRAs by offering “benefit credits” of up to $500 for employees to use towards various wellness programs.

Treating people with chronic health conditions accounts for 90% of the $4.1 trillion the U.S. spends on health care. Many of these conditions are related to unhealthy lifestyle choices, such as poor nutrition, heavy tobacco use, and alcohol and drug use, among the leading risk factors for early disability and mortality in the U.S. It is estimated that one out of every four dollars that employers pay for health care is correlated to unhealthy lifestyle choices. This means that a considerable percentage of employer healthcare expenses are preventable.

HRA programs can help combat this, but few people fill them out. In fact, according to a survey conducted by Cigna, about 73% of surveyed employees failed to complete their assessments. However, implementing and encouraging innovative and integrated HRA programs paves the way for individuals to make healthier lifestyle choices. This implementation translates to a shift in behavior, which reduces the amount of money that health insurance companies must pay in claims — a win-win for both employers and their employees.

3. Robust predictive analytic capability to create prospective risk models and focus on high-risk cohorts

Predictive analytics have found their way into the healthcare industry, especially over the last several years. Health plans have incorporated these predictive analytics into several facets of their business, especially in risk adjustment and scoring around high-risk patients.

Health plans use predictive analytics to assess a patient’s risk using claims, third-party, and biometric membership data. Even further, we see health insurance companies can also use analytics on their operations. Seeing and predicting their process gaps, bottlenecks, or failures before they happen is vital for their bottom line.

Even though many health plans have invested in predictive analytics for high-risk cohorts and prospective risk models, the investment is not an easy jump to make. Time, money, and trained personnel are needed to effectively integrate predictive analytics around risk adjustment.

However, those not actively participating in the new change are severely disadvantaged, burdened by less knowledge than their competitors, less security, less visibility, and finally, less data to use when making key decisions around patients and resources.

Patients using a health plan that has adapted these analytics have more visibility into the costing method, security, and increased safety, knowing they are being charged and treated correctly. On the other hand, health plans see reduced costs, increased product value, and reported patient satisfaction. These takeaways for the patient and health plan make predictive analytics a popular investment when looking toward the future.

Talk to us to learn more about how our health plan solutions can help your organization reduce risk and optimize outcomes.

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Richard Chrzasz Headshot
Richard Chrzasz

Richard’s career is focused on process improvement, business resiliency through strategic initiatives such as M&A, and operating model transformation. He leads the Healthcare Consulting Advisory Services for Sustainable Healthcare, working with organizations that are pursuing more sustainable business models that can offer financial and competitive value opportunities. Richard co-leads our Enterprise Management Performance practice, working alongside industry leaders to partner in their sustainability objectives and deliver quality outcomes.

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