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Within the population health community, it is well known that a small percentage of health plan members with chronic conditions are typically responsible for the lion’s share of plan costs. This portion of the employee population is often referred to as the 5-7%, or highest-cost claimants/members. For this group, the top three physically and emotionally debilitating diseases they face are often diabetes, cardiovascular disease and pulmonary heart disease. While it is important that all members be informed about their network and primary care physician (PCP) options, so as not to seek services out of network and to avoid duplicate therapy, it is especially important that the 5-7% be actively supported and proactively informed of their healthcare options and the many prevention steps wellness managers can provide. Chronic diseases can ravage an employee’s morale and motivation, which in turn effects their work performance and health outcomes. An unmotivated employee with a chronic condition is less likely to exercise, or comply with wellness program protocol. As a result, the member is not engaged in proactively improving their health, making it difficult to fully optimize the health plan. Predictive modeling and health data analytics makes it easier to target these individuals and chronic conditions and put prevention steps in place to improve health and cut unnecessary costs. 

“Having a user-friendly data analytics tool gives case managers more time to focus on their patients and less time combing through data to find patients who need interventions.” Barb Rutkowski, Care Manager at Advanced Plan for Health

A good predictive modeling engine assigns risk scores to individuals within a population – identifying people whose health profile suggests elevated risk. Case managers can then improve outcomes and lower costs by assisting patients at risk of catastrophic events, improving their health through timely interventions. Below are three of the costliest diseases ravaging your health plan, along with prevention strategies for each. 

Pulmonary Heart Disease:

  • Limit sodium intake

  • Daily weight and symptom monitoring 

  • Smoking cessation

  • Monitor blood cholesterol

Example:  Where there is no electronic monitoring, someone with congestive heart failure can work with the wellness manager/care coordinator to get a baseline weight and follow a simple daily regime of monitoring and controlling fluctuations in water weight to decrease the likelihood of costly emergency visits or inpatient admissions.  First, the participant posts a sheet of symptoms and interventions tied to “stoplight colors” signifying urgency—red, yellow and green.  Next, the person weighs in on the same scale every day, and records the weight on the calendar placed by the scale and compares any sudden weight gain to the symptoms and interventions listed on the “symptom” sheet beside the calendar to determine the action to take.  It’s a simple routine, and it puts the individual in charge of self-monitoring and taking pre-emptive action to control heart failure and get necessary help.

Diabetes: Although diabetes can be difficult to control and is often hereditary, there are several prevention steps you can take.

  • Group and individual biometric screenings

  • Choose whole grain over processed carbohydrates

  • Limit red meat intake – and when you cannot, try to avoid processed meats

  • Moderately consume alcohol

  • Move it!  Get 30 minutes of exercise most days and right-size your weight

Example:  Many of our clients offer biometric screening, or individually enter values on individual profiles during onsite visits.  Advanced Plan for Health’s Poindexter features a summary of biometrics on all group participants. Group screening test values can be submitted and uploaded into Poindexter.  Once these metrics are loaded into our analytic engine, the wellness manager/care coordinator can see all individuals with abnormal values or those with multiple risk factors for Metabolic Syndrome.  For just one client last week, five new diabetics were found, who were then enrolled in Nurse Navigation and diabetic education, while others joined the watch list.  Most of these patients have appointments with a dietician, as well, to improve their nutrition within their lifestyle and means. The best part is that this summary of all biometric test results is in one table on a single online page, divided by whether they are outliers (highlighted in red) or in the normal range (highlighted in green).  Once the wellness manager/care coordinator decides on the search criteria; i.e., fasting blood sugars over 180 or A1cs over 7, all it takes is a couple of clicks to reach the individual level, where the abnormal values can be studied in the context of the whole person.  Then it’s a matter of formulating a plan, taking action, setting goals and calendar reminders, working with the individual, capturing savings, making referrals, reviewing the medical experience, monitoring drug compliance, writing notes, and more, all within an easy-to-use medical management module.  So easy!

Cardiovascular disease:

  • Keep your A (A1C), Blood Pressure, Cholesterol in check

  • Determine efficacy of daily aspirin regimen 

  • Engage in doctor-approved physical exercise regimen

High-cost claimants are only a part of the equation. There is a secondary subset of the insured population who are at-risk of entering the 5-7% of highest cost claimants that predictive modeling can uncover and help address. Not all predictive modeling engines have the capability to identify this subset of the employee population, but with Advanced Plan for Health’s Poindexter’s predictive modeling capabilities, determining the likelihood of an occurrence of coronary events, neurological events, orthopedic events and chronic kidney disease is made easy. Once interventions are made to improve the health of at-risk patients, the analytics system can retrospectively report actual cost versus the original predictive model to measure the positive health and financial effects the interventions created. Without the predictive-modelling enabled ability to identify those at-risk and intervene with targeted prevention strategies, health plan optimization will always be an uphill battle. 

One last thought: Little things mean a lot. There is so much detail involved in achieving a strong bottom-line for clinical, financial and satisfaction measures. Keeping it all in your head is much too stressful. Poindexter takes the pressure off. Wellness managers/care coordinators can place a reminder on their Poindexter calendar to contact a participant about an upcoming visit, filling a prescription, a reminder to get bloodwork, or just offer a little encouragement. The calendar feature is a great way to start the day, because it aggregates reminders for all participants on one opening work page. By clicking on an individual name, the user can read the note made previously on what you intended to do for this person today or maybe the personal message that you intended to deliver, “How did your Mom’s surgery go yesterday?” or “Is the new blood pressure medicine working?” or “Are you still losing one pound a week?” Following through with your promises and remembering details important to each individual participant are the personal touches that convey how much you care. After all, getting the jump on chronic cardiovascular conditions requires participants to make lifestyle changes and comply with their physician’s treatment plan, and that is hard for all of us to do. The first step is to get folks to work with you, so that you can sustain them through the changes and help them improve their life habits. Poindexter helps you do just that.



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