Prevention Improves Quality & Revenue, But Have Your Members Gotten the Message?

While Benjamin Franklin’s famous quote, “An ounce of prevention is worth a pound of cure” was actually referring to fire safety, this old adage could just as well apply to healthcare. Patients who have an established relationship with a primary care physician (PCP) receive more coordinated, timely and accessible care, resulting in fewer ER visits and hospital admissions. But, how many of your members actually have and seek care from a PCP? HMS recently analyzed customer data and found that approximately 44% of adult members did not have a PCP they have an established relationship with, and 72% had not had a preventive care visit in the last year. This is problematic for payers and members.

The Benefits of Preventive Care for Plans and Members Alike

From a member perspective, people are more likely to visit the ER or urgent care if they don’t have an established relationship with a medical practice and a familiar face that provides them with care. PCPs understand their patients’ medical histories and focus on treating underlying health conditions, rather than simply the symptoms. Individuals without a medical home are also less likely to get the help they need to identify and manage chronic conditions. Gaps in preventive care are a concern for payers because they result in increased costs, lost revenue and lower quality. We consistently find that members who report having a PCP they work well with have higher rates of gap closure than those who do not, a difference of up to 20% in some cases.

Many payers focus on quality measures when communicating with members about preventive care. For example, female members may get reminders about breast cancer screenings, but only if they are over 50, or chlamydia screenings, but only if they are under 24. Many members, especially men under 50, may not receive any preventive care screening reminders, simply because they don’t fall into a quality improvement measure, even though disease risk, such as heart disease, increases after 40.

Even if an annual wellness checkup isn’t a quality improvement requirement for all your members, reminding people to get an annual wellness checkup is an effective way to increase the number of individuals with a PCP. And if the patient is covered by government-sponsored insurance, such as Medicare or Medicaid, any diagnoses captured during the visit will influence risk adjustment, which can offset the cost of increased care for higher risk members.

Let’s say a member goes to his or her doctor for a wellness visit. During that encounter, the physician discovers that the patient is diabetic. The doctor will add the diagnosis code for diabetes to the claim. When the health plan receives this information, it flags the need for additional diagnostics, such as a yearly HbA1c test, a nephropathy screening, annual eye exam, ongoing blood pressure monitoring and more. This data can be used to prompt the member to schedule appointments for these important services, and a government-sponsored plan will be reimbursed at a higher rate to compensate for the additional costs of managing a higher-risk patient.

To further illustrate, the Better Medicare Alliance developed an example of risk-adjusted Medicare Advantage payments for two fictional members. A 65-year old woman with rheumatoid arthritis, who is otherwise healthy and is not low income, would represent a $547.04 monthly payment to the plan. In contrast, an 88-year old, low income man with lung cancer, diabetes, macular degeneration and depression would represent a $2,268.79 monthly payment to the plan. This example demonstrates that the individual with higher clinical and psychosocial needs will require more support from the plan sponsor, and will therefore receive higher compensation to that end.

How to Encourage Preventive Care

Preventive care is a win for members and the plans that cover them, but unfortunately, most people put off going to the doctor until they are sick.

HMS’ Eliza member outreach solution can help. Our engagement programs encourage members to get to their PCP. We identify individuals who have gaps in preventive care, reach out to them via a variety of channels, including IVR, email and text, provide education on the importance of annual wellness visits, and can even help schedule appointments and transportation.

Here are two examples of how health plans have used Eliza to encourage members to participate in preventive care:

1. Closing Gaps in Care for Diabetes Patients

In late 2017, a national health plan targeted 3,750 Dual Eligible Special Needs Plan members who had a diabetes diagnosis, as well as open gaps in care. The plan’s objective was two-fold:

  • Scheduling provider appointments to close care gaps
  • Ensuring that Risk Adjustment Factor (RAF) scores reflected the disease burden of the population

The plan leveraged Eliza’s proprietary propensity modeling, segmented messaging and member outreach strategies. These, in combination, delivered impressive results. After five months of claims runout, 956 members completed an appointment and their RAF score increased from 1.382 in 2017 to 1.595 in 2018. This translated to $2.175 million in additional revenue for the plan – a 27:1 return on investment.

2. Increasing Primary Care Physician Visits and Star Bonus

A Medicare Advantage plan wanted to improve diabetes measures from 3.5 to 4.0 stars by influencing 500 additional members to schedule a PCP visit. The plan turned to the Eliza team for help. The results were a 14% increase in potential appointments and a $22 million potential star bonus for the year.

Getting members, especially those in high-risk categories, to the doctor on a regular basis for preventive care is a proven way for plans to reduce the cost of healthcare. An essential first step is helping members find a PCP, followed by ongoing reminders about different screenings and healthcare services that can prevent more serious conditions from developing.

To learn more about how HMS’ Eliza engagement solutions can help your plan promote preventive care, improve member outcomes and generate savings, contact us today.

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