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Understanding Your Health Care
Published Wednesday, December 14, 2016

According to the Centers for Medicare and Medicaid Services (CMS), “The $2.9 trillion we spend annually on health care—a whopping $9,200 per person—isn’t necessarily buying us the best care or ensuring good health.”

At least two decades of statistics suggest there is an inverse relationship between employer health costs and employee health status. After all, research from the Kaiser Family Foundation shows premiums for employer-sponsored health insurance increased 203 percent between 1999 and 2015. Contemporaneously, the prevalence of employee obesity, diabetes, high blood pressure and chronic illness has grown exponentially.

This dynamic has left many employers, and especially their finance and human resources staff, feeling powerless.

At Geneia, we strongly believe there is a compelling opportunity for employers to reverse  this dynamic and improve the quality and cost of health care. It begins with timely data and actionable insights and employer willingness to use this information to hold health plans accountable for the return on investment on their health care spend. In our experience, there are eight questions the savviest employers pose to their health plan about reporting:

1. Timeliness: How often is the data updated and how frequently do your employer clients access the information?
Employers’ access to claims information often lags by months. Employers need access to real-time clinical and claims information to impact health care spending this year and make benefit changes for the year ahead. The frequency that employers access health plan reporting is a bellwether indicator of how often the data is refreshed and how relevant the information is.

2.Usability: Is your reporting self-service, readily understood and actionable by existing human resources staff, and is it comprised of drill-down capabilities for further exploration?
Human resources staff juggle many competing demands, and most have limited time to focus on employee benefits and do not have analytics expertise. Therefore, it is imperative that health plan reporting is on-demand, available precisely when employers want it and actionable by existing staff.

Furthermore, rather than needing to request ad-hoc reports from their health plan or broker, employers need easy-to-use dashboards with drill-down capabilities to, for example, learn
more about the cost drivers for high-risk employees who have not seen their primary care physician in the past 12 months and preventive care compliance for diabetics.

3. At-Risk Employees: What’s the risk score for my at-risk employees and how has their risk score changed as the result of the health plan’s case and disease management programs?
At a high level, the goals for health plan engagement are to identify the risk status of employees and work to maintain the current status and prevent further deterioration. In other words,

  • For Healthy Employees: Keep them healthy
  • For At-Risk Employees: Prevent or delay chronic disease
  • For Chronically-Ill Employees: Slow or halt disease progression

The savviest employers not only know which employees have been identified for health plan case and disease management programs and the percentage who are actually participating, but more importantly, how the risk score has changed for the engaged and non-engaged populations.

4. Rising-Risk Employees: How do you predict which employees are likely to get sick and how do you prevent them from developing chronic disease?
Increasingly, predictive analytics allow health plans to successfully identify which members are likely to become sick in the next 12 to 24 months and then intervene to prevent chronic illness. For example, identifying the pre-diabetics within an employee population and combining this information with preventive care compliance and medication adherence data enables health plans to effectively direct care management.

5. High-Risk Employees: How do you incorporate biometric data to mitigate disease progression?
For the highest-risk employees, studies have proven the effectiveness of capturing real-time changes in biometric data such as weight, blood pressure and pulse oxygen, and integrating this data with additional clinical and claims information to create a comprehensive 360-view.

A Geneia study of health plan members diagnosed with heart failure demonstrated that remote monitoring facilitated earlier interventions by the member’s care team and prevented avoidable hospitalizations and disease progression. In short, the heart failure patients in our study fared much better than the control group.

6. Disease and Condition Prevalence: Which conditions have the highest per member per month costs for my employees, and of those conditions, which can be improved with behavior change and wellness initiatives?
To make more of a cost and quality impact, employers’ wellness investments increasingly are targeted to particular groups of employees. This means employers will need timely access to data such as disease and condition prevalence among their employees, associated costs, and treating providers. The savviest employers have begun directing their wellness resources to the conditions most amenable to behavior change.

7. Sub-Population Trends: What are the readmission, hospitalization and emergency department trends by sub-populations such as the healthy, at-risk, and chronically-ill?
Since we know certain sub-populations are higher utilizers of avoidable healthcare services, the usefulness of aggregate numbers is limited. Therefore, it’s imperative to have access
to sub-population trend data to more effectively manage the cost and quality of care.

8. Pharmacy: How accurate are your estimates of specialty pharmacy costs and how do you impact employee site-of-service for specialty pharmacy?
The estimated number of Americans with annual drug costs greater than $50,000 increased 63 percent in 2014, and current trends suggest specialty drug spending will total $400 billion by 2020, or 9.1 percent of national health spending.

As the steward of employer health spending, health plans will need to do more to estimate and control specialty pharmacy costs, including evaluating the cost and quality by site-of-service and directing employees to higher value care.

Health plans may be surprised to learn that nearly all employers already know advanced analytics help them make better healthcare decisions, and 83 percent say advanced analytics is the only way to lower health care costs and improve results.

In the face of increasing costs and declining employee health, employers have had to become more skilled at asking the right questions and holding their health plans accountable for the answers. The most innovative health plans know this, and are already providing their employer customers with actionable and timely reporting enhanced with advanced analytics.

Heather Lavoie is the chief strategy officer for Geneia, a health care technology company with offices in Manchester.

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