The Centers for Disease Control and Prevention report that 70% of all health claims are lifestyle or behavior related. What's more, most individuals with chronic conditions have several comorbid conditions.
Such prevalence of comorbidities means our nation's segmented health care system is trying to treat more than one condition simultaneously, usually having one individual meet with several medical providers.
New technologies combat this problem by identifying at-risk individuals and reaching out to them with coordinated care management programs designed to cater to all of their conditions simultaneously and funnel them into the appropriate wellness programs.
"If you can get everyone on the same exact platform - suppliers, carriers, brokers, HR, the CFO and members - then the workflow engine is integrated within that platform, and it's very easy to push activity out to the members," says Henry Cha, president of Maryland-based Healthcare Interactive, whose Campaign Builder software allows employers to see in detail how their employees are using their health benefits.
"Technology is now able to drill into a plan based on an analysis of historical claims data - clinical and prescription drug claims data - and run that information through cutting-edge data warehouses, which have come up with almost a 95% accuracy rate," details George Pantos, executive director of the
"[We can] predict with that degree of certainty what the workforce faces in the way of health risk, which leads to a better understanding of what's going on in the plan, where benefits dollars are going, where the costs are, what the health profiles are, and then can lead to actionable strategies to cope with those actions, he adds.
The software coordinates with care management, nurse coaching, disease management, smoking cessation and obesity-control-type outreach programs. There is an educational outreach component of health performance management as well.
For example, a company might identify a high proportion of the workforce uses Lipitor, a red flag and risk factor for high cholesterol and possible cardiovascular problems.
It would send out communication to the workforce population, offering a wellness program aimed at people who use Lipitor and want to lower their cholesterol.
"It's not easy [to reach out to employees and get them to change their behavior], but it's a lot less impossible getting involved earlier in the condition rather than later," says benefits broker Bill Lavis, executive vice president at Sitzmann Morris & Lavis, whose clients use Healthcare Performance Management software to identify potential health risks.
"I'm never going back to a traditional system ... I have a crystal ball that I never had before, and that [tool] allows me to identify the highest and potentially emerging high-risk individuals within a group," he adds.
Compliance with HIPAA
The technology avoids violating HIPAA because "analytics are performed for the total workforce in an individually agnostic, secure, HIPAA-compliant manner," Pantos says.
The software allows employers to offer a member engagement tool - like a Facebook application - that lets employees interact on a secure Web-based platform with doctors, labs and pharmacies, and aggregate all their individual health information online.
Companies have reduced annual costs by 20% to 25% using HPM technology, including Men's Wearhouse, which saved $3.3 million between 2009 and 2010 by changing the way it administers its plan.
"Instead of relying on insurance companies and outside managers to deal with [rising costs], companies can take control of their own health plans and begin asking the right questions" if the technology and data are in their hands, Pantos explains. "Taking control of the health plan is significantly transformative for the function of an employer plan sponsor."
Focusing on unnecessary surgeries
2008 data from the Centers for Medicare and Medicaid Services reveal that the United States spends $2.3 trillion on health care and $700 billion on surgery (the largest single sector in health care.)
"This sector is somewhat unmanaged, compared to pharmacy, where there are pharmacy benefit managers," says Vic Lazzaro, CEO of
When researchers at Dartmouth University studied unnecessary surgery, among participants who had information on the surgery, its risks and alternatives, 22% to 44% elected a simpler procedure, alternative treatment or no surgery.
BridgeHealth technology encourages transparency that aids patients in making the right decisions, and everyone - the patient, employer and payer - knows in advance what the cost will be.
The technology analyzes and groups data by procedure cost. It shows an employer historical data on how many surgeries there were, what kind, how much money was spent and - if they had used the BridgeHealth Centers of Excellence - how much the company could have saved.
BridgeHealth demonstrates the savings with an employer's own data, then creates a predictive model to determine who might need the surgeries in the coming year and to stratify the probability of them having that surgery. In the end, the individual and the employer save money, and the employee gets better quality care.
"It's going to be the way of the future. As health care reform percolates in the next couple years, companies - employers, medical management companies, insurance companies - are trying to develop the tools and software that allow a company to truly self-manage their health plan," Cha says.
"Employee cost sharing is not cost control, it's just cost shifting," says Pantos. "You don't have to shift costs, what you have to do is reduce them." Companies can do so with technology that fosters data analysis combined and integrated with targeted outreach.
Texting transparency
Since introducing a high deductible health plan in 2003, Thompson Machinery encountered friction from employees who didn’t understand the new plan or who had trouble acclimating. The company introduced change:healthcare’s cost transparency solution in April 2010 because in response to employees’ calls for decision support.
The technology works best with self-insured employers because they can easily acquire their employee population’s health data, as opposed to if they were on an individual plan or fully-insured. It culls data from medical, vision, dental and pharmacy sectors, and shows the lowest-cost choices for services according to geographic preferences and network. It delivers cost savings alerts to employees via e-mail or text message. Employees only get a message if there are savings, so there’s no unnecessary noise from generalized, unhelpful e-mail blasts.
Once Thompson Machinery aggregated its data, officials saw heavier medical benefits users had big savings — sometimes as much as $1,000. Through the data they can see progress and have already have moved past breaking even on the investment.
Warpool believes they’re giving employees all of the power to make decisions.
“Knowing that employees are going to be increasingly responsible for higher deductibles and higher coinsurance, cost transparency tools are not a choice, they are a requirement,” asserts Christopher Parks, CEO of change:healthcare.
“Customers are very important, but if you don’t take care of your employees you won’t last too long. The more opportunities that you can reach out to your employees to make them feel that they’re intelligent enough to make decisions, the more that you engage those employees and make them feel that they have the ability to impact the success of the company, [the better],” says Scot Warpool, corporate training and recruitment administrator, Thompson Machinery.
