Most managed care leaders are already well versed in the statistics around treatment adherence. They know that, at any given time, approximately 50% of people with chronic diseases are not taking their medications as prescribed. Other types of compliance, including recommended screenings (e.g., A1c tests for diabetes) can be just as challenging.
The problem of nonadherence is hardly new. It has been recognized for decades as one of the causes of poor health outcomes and high healthcare costs.
But one thing has changed. The industry now has a better understanding of how complex and multidimensional nonadherence can be. Barriers are multifactorial and include treatment-related issues (e.g., side effects), mental health problems, and health system factors (e.g., lack of care coordination). In recent years, the role of social determinants of health has also become clear. These include food, shelter, and transportation insecurity, as well as an inability to access or pay for day-to-day necessities of life.
Trying to help members with these varied and sometimes interrelated issues can seem overwhelming. However, one approach has been shown to consistently help the majority of high-risk members become compliant with care plans and improve their health. It’s a targeted, individualized, and high-touch approach to care management that involves:
- Data analytics to pinpoint the right members to reach out to at the right time
- Personalized interactions between members and a care management team
When deployed, this approach has provided a ROI of greater than 2:1 for payers, while making significant strides in helping members improve their health.
A member story
The following story of Samantha Smith (not her real name) is a good example of how individualized, high-touch care management can assist high-risk members with complex care needs. Numerous barriers got in the way of Samantha’s ability to stay compliant with her diabetes care plan. When a care management team first met her, she was homeless and had unmanaged bipolar disease along with a history of substance use.
Not surprisingly, Samantha used a lot of expensive healthcare services. One year, she visited the emergency department (ED) 22 times.
Yet Samantha had a good reason to turn her life around: She was pregnant.
To help Samantha, the case manager obtained two grants to cover Samantha’s housing and utility bills. The case manager also referred Samantha to an obstetrician and mental health provider and then accompanied her to the appointments. In addition, the case manager helped Samantha stay on top of the medications she needed to take and connected her with substance abuse resources.
This story shows that members can turn their lives around fairly quickly with the right assistance. Within nine months of entering the case management program, Samantha had delivered a healthy baby boy and was drug-free and housing and food secure. She also had zero inpatient or ED visits during this time frame, except to deliver her baby.
Keys to success
Samantha deserves a lot of credit for her success. But the care management approach also played a critical role. Specifically, four factors help ensure success in terms of health outcome improvements and cost reductions:
1. Identify members who are likely to have near-term, high-cost events. A common approach for assigning members to care management is to identify high-cost outliers. However, a better ROI can be obtained by pinpointing members who have gaps in care known to significantly raise the odds of hospitalization or other high-cost events in the next 6 to 12 months. For instance, evidence-based research shows that taking mission-critical medications (e.g., metformin for type 2 diabetes) can help stabilize and improve a patient’s health status and reduce unnecessary utilization.
Predictive analytics can be used to sort claims data to identify members with mission-critical care gaps. Other types of data, including consumer data, can inform these analytical models and help identify members who might be struggling with transportation insecurity and other social determinants of health.