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Improving the health of your employees and health plan, while positively impacting clinical and financial outcomes, is critical to getting the best benefit. This blog explains how to do it.To ensure cost-effective, quality health care, you need to control and manage your health plan like you do your core business. That means making sure that clinical and wellness initiatives are working as intended, and integrated among the member, insurer, plan and the provider team.

Population Health Management (PHM) is the continuum of care from wellness to catastrophic conditions across all treatment settings. A successful PHM plan in large part depends on the help of a local Nurse Care Navigator (NCN) and their ability: (1) to address the causative factors driving health behavior and lifestyles, (2) to arm them with education and support, and (3) to network proactively with local providers, the insurer and community resource; thereby avoiding expensive emergent and inpatient occurrences. A well trained NCN will delve deep to better understand the problem, work with targeted members and providers, and then monitor interventions both at the macro and micro levels to be sure that they are working. In addition, they will be trained and experienced enough to ask—and help answer—wide-ranging rhetorical questions meant to improve plan efficiency: 

  • Do you have adequate data transparency and input in evaluating wise resource allocation, utilization, and impacting decision on intervention
  • How do vendor savings align with the plan metrics and the checks written by your CFO from your self-insured account
  • Who sought care out-of-network during a user-defined timeframe
  • Who had 3 emergency room visits in the past three months 

The end results of posing, and answering the right questions are credible and measurable “bottom-line” metrics that match the Health Plan medical and pharmacy claims reports. Unfortunately, even the most savvy of NCNs are limited by their resources. Employers need state-of-the-art intelligent data systems (Poindexter) to optimize the overall health and well-being of their workforce and families across the health continuum. This intelligent data system receives medical and pharmacy claims reports, and may also integrate biometric data, laboratory results and even health risk assessments. Quality processes and measurements, which enable employers to analyze and improve costs in their core business down to a fraction of a penny, are instrumental in optimizing health plan clinical and financial outcomes. 

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