Data can help health plans identify medically at-risk members and intervene with the appropriate prevention and wellness programs to keep them as healthy as possible and avoid a costly trip to the doctor or emergency room.

Effective prevention and wellness programs are critical to health plans’ financial success. Keeping their healthy enrollees healthy and their chronically ill enrollees as healthy as possible are business imperatives. Private health insurance plans will be picking up more than one-third of the nation’s projected $3.8 trillion healthcare bill this year, according to the latest data from the Centers for Medicare and Medicaid Services.

Promoting prevention and wellness programs aren’t new objectives for health plans. Insurers typically encourage preventive health and wellness through two different avenues. First, many health plans cover most or all of the enrollees’ cost for services like preventive screenings, annual physicals, well-woman gynecological visits and immunizations. Second, many health plans offer wellness programs aimed at living a healthy lifestyle. Some health plans, for example, include programs to help members stop smoking, lose weight or manage chronic illnesses such as diabetes. Many plans also offer incentives—such as discounts on gym memberships, lower premiums and other financial incentives—to motivate members to participate and improve their health status.

But in order to develop these focused prevention and wellness initiatives, health plans must first identify at-risk members and stratify them by their medical risk. The question is—how?

The key is capturing and capitalizing on data. Data obtained from performance measurement programs—such as HEDIS® (Healthcare Effectiveness Data and Information Set)—can help health plans identify members at risk for medical issues and, as a result, intervene with the appropriate prevention and wellness programs.

Leveraging Standardized Measures

HEDIS is a set of standardized performance measures developed and administered by the National Committee for Quality Assurance (NCQA). It’s one of the healthcare industry’s most widely used performance improvement tools, with more than 90% of health plans using it, according to the Agency for Healthcare Research and Quality (AHRQ).

HEDIS provides standardized measures across six domains—effectiveness of care, access to and availability of care, experience of care, utilization and risk-adjusted utilization, health plan descriptive information, and measures collected using electronic clinical data systems—to specify how healthcare organizations collect, audit and report performance information. It also incorporates patients’ assessments of their experiences with their care, according to AHRQ.

Many of the measures evaluated by HEDIS to accredit health plans are preventive. For example, the data obtained by NCQA indicates whether a member has had a medical service or not, flagging a potential gap in care.

Consider this fictional scenario:

Mike is 58 years old and has chronic obstructive pulmonary disease (COPD). The Centers for Disease Control and Prevention (CDC) recommends that adults younger than 65 with certain chronic health conditions such as COPD get the pneumococcal vaccine, which immunizes them against pneumonia. However, data from Mike’s claims history or EMR shows that he hasn’t visited his doctor in a while or had the vaccine as recommended by the CDC.

So what happens next? Mike’s health plan can encourage him to visit his doctor and send him information on why the pneumococcal vaccine is important. By helping steer Mike in the right direction, the health plan can help keep him in good health and potentially out of the hospital with complications caused by COPD or even with pneumonia.

By leveraging this type of information, a health plan can ensure better outcomes. When members are healthy, it helps keep costs down as well.

Capturing Social Determinants of Health Data

Prioritizing HEDIS and other standardized performance measurement data sets can help health plans improve their population health management programs. Armed with extensive clinical data, health plans can identify and stratify members based on their risk of developing illnesses such as diabetes, heart disease, COPD or other chronic conditions.

But while their clinical history is important, there’s more to the patient’s health story. Some patients don’t have transportation to get to doctors’ appointments, lack support from family or friends, or live in a “food desert,” where finding affordable healthy produce or unprocessed foods can be difficult. That’s why healthcare organizations, including payers, are beginning to integrate those social determinants of health (SDOH) into their population health management strategies as well.

According to a Change Healthcare study from 2018, 42% of payers are integrating community programs and resources into their population health efforts and another 34% are using census and socioeconomic data, in addition to the clinical data, to create new programs.

It’s harder to standardize that type of data, but it’s still important to consider, and the industry is starting to do it with several important initiatives in the commercial and public sectors. What’s happening with the patient between doctor visits—that’s when life is happening, and that’s actually more important.

That’s why many health plans are hiring social workers to help address some of the issues related to SDOH, explains Cate Higgins, RN, senior clinical consultant at Medecision.

“They have the expertise to dive in and find out what’s preventing the member from getting the care they need. They can help them utilize community resources, get financial assistance or arrange transportation to appointments,” Higgins says.

Treating Members From Head to Toe

Without the data and analytics captured by performance measurement programs, health plans wouldn’t have the tools needed to understand the population, says Noreen Stauffer, RN, senior director of clinical consulting at Medecision.

“The data can help drive engagement with members,” Stauffer says.

Health plans with successful population health management strategies “transition away from a single disease-focused program to a ‘whole person’ approach that is more holistic, effectively addressing all of a member’s conditions,” according to America’s Health Insurance Plans, the national trade association that represents commercial health plans..

Many health plans moved toward these holistic model years ago, Higgins explains, but some are just now starting to roll out these approaches within their organizations.

“You no longer have a case manager who is an expert in heart failure and another one who is an expert in diabetes,” Stauffer says. “There are now multidisciplinary teams where a nurse owns a member’s case, but she can also refer them to a pharmacist, social worker, behavioral therapist or other specialist. Health plans are making an effort to look at the member from head to toe, including medical, behavioral and even emotional issues.”

Data can identify the enrollees who need the most help and direct the multidisciplinary team on how best to care for their patients.

Medecision’s Aerial Experience helps organizations optimize performance under HEDIS and other quality measurement programs, and improve consumer engagement. To learn more, visit or follow us on Twitter @Medecision or LinkedIn.

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