Member Segmentation: The Key to Effective Care Management

February 24, 2020 HMS

Health plans are discovering that care management is an effective way to improve member outcomes and reduce costs. The unfortunate reality, however, is that care management resources are limited. To make the most of these resources, health plans must focus on the highest risk, highest cost members. It’s also essential to keep an eye on “rising risk” members who may be on a trajectory to shift from medium risk to high-risk groups.

A recent Advisory Board Company survey of Chief Transformation Officers found that managing high-risk patients is a high priority, but only a small number of organizations feel that they are managing this patient segment effectively. With high-risk members, insufficient care coordination leads to higher care costs. People with multiple chronic conditions are often treated by several different specialists who may not have insight into one another’s treatment plans. To be successful in their roles, care managers must have access to a comprehensive, holistic view of each patient across the care continuum. This is the only way to identify and deliver the right care to individuals at the right time.

High-risk members shouldn’t be the only priority patients for care management teams, however. Health plans must also consider how to prevent lower risk members from escalating into higher risk groups by shifting their focus beyond just “sick care,” to “well care.”  According to the Advisory Board Company, each year close to 20% of medium-risk patients escalate and become high-risk patients. This group represents a significant cost reduction opportunity.

To derive the greatest return on care management investments, health plans must segment their members. The Advisory Board Company suggests three best practices:

  1. Segment members by risk level into high, medium and low risk groups.
    Each segment has its own distinct goals and care needs. Lower risk groups have lower cost needs, so utilizing a single population health management platform for these members, as well as for high-risk members, results in unnecessary expense. Health plans need predictive and prescriptive analytics to segment members and ongoing data analysis is also essential, since the population of rising risk members is always changing.
  2. Deploy high-risk care managers who can develop one-on-one relationships with members.
    One of the primary goals for high-risk care managers is to identify appropriate sites of care for members. In most cases, these represent lower cost alternatives than emergency rooms. Care managers coordinate care across multiple providers, educate members, manage referrals to specialists and encourage frequent communication with both members and providers. Care managers must also be able to address psychosocial and non-clinical barriers to care. An Advisory Board Company survey found that over half of providers (57%) utilize high-risk care managers and over three quarters (88%) of high-risk care managers coordinate care for 200 patients or less.
  3. When identifying rising risk members, focus on risk factors rather than disease states. Growing numbers of health plan members have multiple chronic conditions. Rather than asking care managers to target specific diseases, it’s more effective to focus on the risk factors associated with multiple conditions. Once care managers identify members with multiple risk factors, a good first step is to focus on preventive care initiatives by connecting these individuals with a primary care physician and “medical home” if they are not already affiliated with one. Other effective approaches for better managing your rising-risk populations in include one-on-one coaching, enrollment in a targeted, multi-modal engagement program, recommend screenings for chronic conditions, and group visits for caregivers.

Care management solutions like HMS’ Essette are an efficient way for health plans to segment their members. Essette enables organizations to stratify their members based on risk level and other health-related criteria. Since it integrates with other systems like claims, eligibility and analytics, Essette helps plans quickly and accurately segment members and then monitor their characteristics over time. This makes it easier to find rising-risk members and to intervene with care management services before their health conditions become more severe.


To learn more about how technology can help your organization segment its members and improve its care management function, contact us.

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