Having access to plan data is a unique advantage in self-funding that gives employers the ability to identify cost-driving trends and make the necessary adjustments to address them. Nova Healthcare Administrators, Inc., shares an example of how this diligent data monitoring led one client to recognize a trigger behind the overutilization of emergency room visits – patients aging out of pediatric care – and reduce this population’s ER visits by 14% in just one year. Find out how medical and pharmacy claims data, biometric and health assessment data and TPA intelligence can all be used to help improve the performance of self-funded plans. Check out the full article below.

For more information or to contact Nova, visit www.novahealthcare.com or call (716) 932-5105.

A Proactive Approach to Plan Data Lowers Number of ER Visits

Health care costs continue to climb with seemingly no end in sight. And, finding the right formula for managing population health and utilization trends has, in the past, proven difficult. So, what can be done to keep costs in check while still delivering a benefit plan that employees want and employers want to offer?

Each plan population is unique. The first step is to identify cost-drivers that are controllable. Then, cost containment strategies can be built by stratifying risk. Focusing on controllable costs such as utilization, care delivery and pharmaceutical spend drives decisions to meet business goals and plan participant needs. To maximize the benefits of a self funded arrangement, TPAs must carefully review medical and pharmacy claims data, biometric and health assessment data and intelligence gathered by the TPA’s employees who work with plan participants daily.

Here’s an example of the positive results Nova Healthcare Administrators, Inc. sees when our customized approach is applied to client-specific cost drivers. One client’s trend showed an increase in and overutilization of ER such that the number of ER visits/1000 in 2016 increased 13% over the prior year. Upon further research, the majority of ER visits were incurred by young adults who aged out of their pediatricians’ office. Nova developed a program to identify these individuals and link them to more appropriate resources through education and outreach. The goal? Decrease ER utilization, decrease the number of inpatient stays/1000, avoid/avert the cost of unnecessary or inappropriate service and close gaps in care. ER visits/1000 for this population decreased 14% in 2017, which was below original 2015 levels. In this scenario, a traditional plan strategy of simply raising the ER copay wouldn’t have had the same impact.

With self-funded plans, having access to data is extremely helpful. But how do you know you’re making good use of this information? Benchmarking plan performance based on national statistics isn’t a true measure of progress. Year-over-year results measured against the plans’ unique demographics is the best way to analyze success. Here are some smart ways to use data.

Medical & Pharmacy Claims Data
Leveraging medical and pharmacy claims data can help uncover the answers to some key questions about plan utilization:

  • Are members getting routine care?
  • What percentage of your population is driving cost?
  • What does provider utilization look like?
  • What does treatment cost at different facilities?
  • Where are plan members seeking care?
  • What diagnoses/treatments are driving cost?

The answers to these questions should drive a strategic approach for the plan going forward. Beyond merely reviewing a static report, you are engaging in surface-level trend management. Take trend management to the next level by digging deeper. It’s necessary to understand why plan participants use the plan the way they do if you’re truly aiming to manage trends. Gather insights from medical and pharmacy claims data. Make meaningful connections between plan utilization and the associated costs. This approach allows a plan sponsor to tailor the plan to address the unique utilization trends and cost drivers in their population.

Biometric & Health Assessment Data
Another key to identifying risk is leveraging the information available through biometric screenings and health assessments. Especially helpful for plans that are newer to the self-funded arrangement, these valuable pieces of intel can fill in the gaps when previous claims data might be unavailable. For established plans, this data provides another lens to evaluate potential plan utilization and identify prospective cost drivers.

Biometric screenings and health assessments can be a proactive indicator of future trends within each population. Uncovering plan participants’ potential or previously undiagnosed conditions can assist in helping members pursue preventive measures or ongoing condition management.

Why wait until you’re paying claims to find out what your expenses will be? Get ahead of the trends and gain valuable benchmarks to help measure results of plan initiatives year-over-year by assessing the current state of the plan population’s overall health.

TPA Intelligence
One challenge many plans face is care and administrative fragmentation – employees, vendors and providers failing to talk to each other. To combat this challenge, it is critical to maximize the value of connectivity through ongoing, meaningful communication.

In failing to capitalize on the value of real-time intelligence that stems from open communication and shared expertise, many organizations miss out on opportunities to have a greater impact on the member experience. From employees who process claims to customer service representatives, every member of the team has the opportunity to gather and share potentially significant information about population trends. By tapping into the insight of each employee and vendor with access to plan information, you build a more robust view of plan activity.

As we’ve found at Nova, a customized approach to trend management and a thoughtful, proactive approach to plan management results in improved health outcomes and reduced plan spend. Only by digging into the data at hand can you identify opportunities that make an impact on reducing trend. When you uncover the right steps to the process, staying ahead of trends is not only an attainable goal, it’s a sustainable one.