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High cost claimants are most responsible for rising health plan costs, but high cost claimants who are addicted to opioids might cripple a health plan altogether

Prevention. Prevention. Prevention.

When it comes to implementing a health plan case management or wellness program, prevention is the surefire way to ensure successful group benefits design and cost outcomes. This is especially true today: Health insurance payers, third party administrators (TPAs), brokers and health plan sponsors, are in the midst of a war against an opioid epidemic that is devastating health plans and has case management teams waving the proverbial white flag. 

“Federal officials estimate that opioid abuse drains nearly $80 billion a year from the American economy because of expenses tied to health care, criminal justice, and lost productivity.”

The current opioid epidemic has shed light on the shortcomings of many wellness programs and the lack of preparedness by case management teams to handle chronic conditions and or patient behavior, such as addictive tendencies or duplicate therapy. But are case management teams solely to blame for lack of effective response to this costly health crisis? The simple answer is, no.

Many case managers do not have access to the data or tools required to employ a compelling and value-driven prevention model. Hence, what we see today is very little accountability or effective case management. What’s needed most is quality data to guide active engagement with patients.

The success or failure of a wellness or case management program is dependent on three things.

  1. Data Quality and Scope
  2. Case Management Team Quality and Experience
  3. How effectively the data is applied and integrated, by the case management team, to the wellness or case management program

Although program success may not rest solely on the shoulders of case managers, it is paramount that case management teams be held accountable for the results they promised. At Advanced Plan for Health (APH) we hold a standard for case management expectations, but not every case management team will meet those standards. In reality, some case management teams are not held to a standard whatsoever.

The Role of Actionable Data in Case Management

For starters, not all data is created equal or is of equal quality, nor does every care team/ case management team have access to data that yields quality actionable insights. Action is the key word. Without action, there can be no prevention. For the most part, care management teams are simply “reaching out” via newsletters that people throw in the trash or send to a spam folder, which has nothing to do with helping the individual stay on Rx compliance or avoid duplicate therapy or going out of network. Current efforts are simply not enough.

Is your member population getting the support and information they need to avoid opioid addiction?

Big data in the form of predictive analytics gives case managers the opportunity to manage locally and work with their hospital or health system to take action and improve health.

Case managers’ first course of action is not only to know what happened to their population over the last quarter or last year. A company that is moving ahead in whatever it’s doing, needs ideas for how to take action in all areas of the company today.

Poindexter facilitates this by allowing case management teams to get a macro view of health plan performance and trends while also providing case managers with the ability to take a deep dive into  “micro” health data as well, so they can impact trends at the personal level and at the plan level. This is only possible with quality data and proper case management. The effective correlation between these two facets of population health management is what translates into case management intelligence and solutions that most case managers do not have access to, which is a significant issue.

Many self-insurerd employers aren’t really looking at healthcare data in a meaningful way. They leave it to the insurance companies. But it’s those brokers, payers and insurers that use data meaningfully that can come up with a plan at the most reasonable price. Predictive analytics can help anticipate where costs will be before they happen, and offer paths to course-correct in time to prevent sometimes significant costs. For instance, Rx (opioid) noncompliance.

Additionally, predictive analytics can help in a multitude of ways: 

  • Reports can give care managers or disease management staff an updated list of covered employees and family members with whom they will consult based on last year’s claims and risk scores. This helps avoid catastrophic medical events that data shows may be on the horizon.
  • Predictive data and trends analysis can reveal to your customers how drug costs and ER utilization can be reduced by identifying which patients, when medically appropriate, can find alternative/less cost care paths – and save them co-pays as well.
  • Analytics and population health information, if given to the right people at the right time, can help an employer manage its covered lives much better. You understand the type of care people are or aren’t getting, and understand where resources need to be allocated.

But it’s more than having the right predictive modeling tool or access to critical information in place. The health plan and plan members do in fact need the right case managers, addressing the right patient at the right time, with the right protocol and procedures that promote prevention to improve both the bottom line and health outcomes. The bottom line is that there must be a standard in place if wellness programs are to succeed. Click here to discover the APH case management standard or for more information visit


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