Preparing for the Chronic Conditions Marathon

Watch the start of any major marathon race, like the Boston Marathon, and you’ll see the same sight: a mass of humanity all bunched together. Often there is little ability to differentiate between the serious runners who will compete to come in first and the more casual runners who are there simply to fulfill a life’s goal.

This view is similar to what health plans and providers see when they look at all the patients/members whose chronic conditions have taken a back seat to battling the COVID-19 pandemic.

They recognize that within this sea of patients/members are some who have an urgent need to address significant care gaps, especially if they haven’t seen or spoken with their primary care or specialist physicians since the pandemic began. They also know there are others who are successfully managing their conditions. They’re just not sure who falls into which category.

Yet knowing there is likely more need in many areas than there is capacity in the system, and that there are huge risks to both health outcomes and costs if they focus on the wrong patients/members, health plans and providers need to ensure they are addressing the greatest needs and risks first.

In other words, determining who has care gaps isn’t enough. Health plans and providers also need to understand the impact closing those gaps will have. Not just in protecting the most vulnerable populations from the worst effects of COVID-19 but on their long-term health as well.

Analytics that go beyond clinical information to incorporate socioeconomic and social determinants of health (SDOH) factors can help healthcare organizations sort through that mass of patients/members to ensure all of them are receiving the proper level of care - and that their internal resources are being used to deliver the maximum benefit to their entire patient/member population.

Predicting need

The first step in winning the chronic conditions marathon is using analytics to predict the geographic areas, and then the patients/members within them, that will have the highest need. This task can be accomplished by matching publicly available information on COVID-19 hot spots (an indicator of where chronic conditions were likely overlooked) against existing data on patients/members, including underlying conditions, clinical gaps and SDOH barriers.

The analysis will then generate a risk score for each patient/member. The higher the risk score, the higher the priority for care managers to reach out to specific patients/members.

As they reconnect with patients/members, providers should harness analytics to determine which interventions will have the greatest impact on reducing risk and how those interventions should be delivered. In some cases, care can be delivered via a voice and video telehealth visit supplemented by user-generated data from consumer devices. In others, such as a need for laboratory tests, diabetic eye exams or cancer screenings, an office visit may be required.

Reopening elective surgeries

Another area where analytics can be valuable in predicting need is in addressing the backlog of so-called “elective” surgeries. Some estimates show that it may take more than a year for healthcare to catch up on the surgeries that were delayed due to the pandemic. And that is assuming the backlog is not made worse by another shutdown in the winter – an assumption for which there is no guarantee.

As health plans and providers open themselves to elective surgeries again, analytics can help them work together to determine which surgeries, if prioritized, will deliver the greatest benefit in reducing the long-term health impact on chronic conditions such as lower back pain. They can also help cash-strapped providers determine the revenue impact of prioritizing some elective surgeries over others.

The health need should always come first. But all else being equal, the ability to generate quick revenue can help providers serve their patients/members more effectively in the long term.

Taking action

Once the needs and priorities are understood, health plans and providers can begin to take action to address them, such as increasing the number of care managers, investing in more formal, HIPAA-compliant telehealth and remote patient monitoring technologies, purchasing supplies and recalling or redeploying staff to prepare for the influx of patients, and deploying strategies to address SDOH barriers.

They should also update analytics and dashboards to measure the effect their initiatives are having to ensure they are achieving the expected ROI. If not, which is not unexpected given the changing nature of COVID-19, they should re-run the analytics and make the appropriate adjustments.

Winning the last mile

Whatever they do, health plans and providers must recognize this is not a short-term fix until everything gets back to “normal.” It really is a marathon.

The effects of the pandemic – not just the health effects but also the financial and operational effects – will be felt for years. Analytics, however, can help them catch their second wind and ensure they come out ahead.

Author Qijuan (Emily) Li leads EXL Health’s Analytics Center of Excellence (ACOE) to create analytical solutions and deliverables for Data & Analytics, Clinical Services, Pharmacy Services, and Payment Services.