by Gregg Bond

Vice President, Channel Solutions

SHPS

Self-insured health plan sponsors manage unique health benefits, underwrite healthcare costs and assume financial risk tied to their population’s health. For third party administrators (TPAs) and employers, today’s healthcare market makes it difficult to optimize the value of a self-insured health plan while still managing escalating costs. Adding to these challenges is the plan participant’s desire for greater support and information when navigating our nation’s complex healthcare system.

How can TPAs and employers subdue spiraling healthcare expenses while boosting the health and satisfaction of their covered population? The answer is simple: integrated care management (ICM).

The first step in an ICM solution is leveraging medical and pharmaceutical claims experience to identify the unique clinical risks driving a population’s costs. This leads to a targeted design of a comprehensive care management program. With the right planning (and the right vendor), ICM improves individual health and healthcare delivery. Lower health plan expenses and higher satisfaction levels are not far behind.

Logical? Yes. However, this approach is curiously absent from many care management offerings.

ICM Evolution

Healthy people cost less to insure than unhealthy people. This is the foundation of ICM. It offers financial and competitive advantages by identifying a population’s health issues, improving clinical outcomes and addressing cost drivers head-on.

ICM components are coordinated to work together to manage:

• Short-term risks via focused identification and intensive nurse counseling for participants at risk for re-admissions, emergency care and/or complex case management; and
• Longitudinal risks via a continual survey of the population – identifying those at risk for progressive clinical conditions, stratifying them, and moving individuals with higher and chronic clinical risk to nurse counseling.   

Encouraging individual health and managing high-risk conditions lowers utilization (including pharmacy claims, re-admission rates, emergency room visits and care complications). When a population’s health improves, other benefits naturally follow – such as stronger morale and greater productivity among the workforce. Additional gains can also be realized by coupling an ICM program with a consumer-oriented benefits package.

 ICM best practices

Although relatively new, experience with ICM programs has already illustrated best practices:

1. Population health metrics identify and prioritize clinical risk.
2. The best interventional approach leverages all relevant data across the healthcare continuum to tailor a unique program experience for each participant.
3. Integrated delivery increases care effectiveness and improves clinical outcomes – now and in the future.
4. Fluid movement between programs as participant needs change is essential to lowering costs and achieving desired clinical outcomes.
5. Care management programs should be measured with valid metrics that monitor short-term results without losing sight of long-term potential.

Successful ICM solutions make healthcare accessible through a portfolio of complementary healthcare and benefits administration products. Benefits of this approach extend to all stakeholders:

• For TPAs, a single source for implementing:
• A uniform healthcare strategy.
• Analytics that support strategic planning and proof-of-effectiveness.
• Consistent participant experiences.
• Integrated reporting on participant activity and clinical outcomes.
• For participants, a single source for:
• Personal intervention strategies.
• Condition management.
• Consistent care advocacy for all health needs.
• For employers, a single source for:
• Effective medical cost control strategies.
• Comprehensive program reporting.
• Integrated service delivery.

ICM covers all risk levels

Healthcare risks span “low,” “high” – and everything in-between. So, ICM solutions should integrate utilization management, case management, disease management and other services to meet every individual’s needs. It should also improve the efficiency and effectiveness of overall healthcare delivery. This holistic clinical system manages each individual using all relevant data across the population health continuum (see graphic).

“Eyes wide open.” It’s the only way to guide the right members into the right programs at the right time.

Setting expectations

ICM fulfills the overarching vision of expert care management working hand-in-hand with targeted cost containment. The results are very promising. Melding data management, clinical interventions and personalized engagement delivers the most promising clinical and financial outcomes.

However, best practice employers are patient. They do not expect significant savings overnight and understand that ICM solutions typically take a few years to reach their full potential. This is why it’s important to temper today’s results with tomorrow’s forecasted savings. Leapfrogging from one approach to another is not only counterproductive to any healthcare strategy – it confuses and disengages the population being served.

High-cost health conditions tend to emerge after years – even decades – of poor lifestyles. Battling them takes concerted engagement, effort and encouragement. With ICM, it may take some time for the roots to form. Yet the fruits are well worth the wait for TPAs, employers and (most important) participants.

Gregg Bond, a vice president at SHPS, is an expert on integrated care management programs and how they fit within TPA models. You can contact him via email at Gregg.Bond@shps.com or by phone at (804) 364-6111.

For more on managing the health of covered populations through targeted, clinically-based care management programs, you can download the 2007 SHPS’ Health Practices Study at www.carewisehealth.com.

About SHPS

SHPS is a leading, independent provider of integrated health solutions that improve personal health and reduce spending. By integrating traditional health management and benefits administration services, SHPS delivers people-centric solutions that empower individuals to make wise healthcare choices. It serves large and mid-sized employers, government agencies, and third-party administrators through the company’s Carewise Health, Landacorp and SHPS brands. Visit www.carewisehealth.com.