The best time to control a high-cost claim is before it occurs. In employee health management, this is achieved by identifying and engaging rising-risk members before their health conditions worsen and their costs escalate.
For self-insured employers, a relatively small percentage of members typically account for a large share of healthcare spending. Traditional care management often focuses on employees who are already experiencing high-cost claims, when the opportunities to change the trajectory of care may be limited.
Just 1% to 2% of members drive 30% to 35% of annual claims for self-insured employers, with an average claims cost of $122,000.
Source: Population Health Management
A more proactive approach starts by identifying rising-risk members, those individuals whose health is beginning to decline but who have not yet required high-cost care. When plans identify and engage with these members early, they can improve health outcomes, reduce avoidable claims, and maximize the return on employer healthcare investments.
Who Are Rising-Risk Members?
On one end of the spectrum, you have healthy, low-risk members. On the other end of the spectrum, you have members who have already experienced catastrophic claims or enrolled in intensive case management. These are not your rising-risk members.
Rising-risk members are somewhere in the middle of the spectrum, moving from the low-risk side to the high-risk side. They may have one or more chronic conditions that are becoming more difficult to manage, and their healthcare utilization is likely increasing. These rising-risk members may also demonstrate declining medication adherence or missed preventive care. There may be new social or lifestyle challenges that affect their health, and they may be exhibiting new behavioral health concerns.
These characteristics are a warning sign. They are also an opportunity for meaningful intervention.
Early Intervention Can Prevent Large Costs Tomorrow
For self-insured employers, rising-risk members often represent the greatest opportunity to improve outcomes before costs accelerate. Although catastrophic claims and productivity loss are increasingly likely, rising-risk members have not yet experienced frequent hospitalizations, high-cost specialty care or disability leave.
Timely intervention can help slow or even reverse disease progression. For example:
- An individual with prediabetes can avoid diabetes.
- An individual with high blood pressure can avoid a stroke.
- An individual with high cholesterol can avoid a heart attack.
- An individual with kidney damage can avoid end-stage renal disease.
The Business Case for Early Intervention
5 Opportunities to Strengthen Rising-Risk Member Management
- Incorporate current data alongside historical claims.
- Engage members before hospitalization occurs.
- Integrate behavioral health with physical health strategies.
- Expand care management to include rising-risk members.
- Measure engagement and health outcomes alongside cost-based metrics.
According to research published in Population Health Management, a third-party review of a self-insured company with 45,000 employees uncovered approximately $35 million in annual avoidable emergency room and hospitalization expenses linked to chronic disease.
By identifying rising-risk members and providing guidance to improve the quality and cost-effectiveness of care, plan sponsors can bring about a reduction in catastrophic claims and medical spending. These direct financial impacts are meaningful in and of themselves, but the benefits of early intervention do not end there. When worsening health outcomes are avoided, employers can also benefit from improved workforce productivity, reduced absenteeism and a better employee experience, all of which contribute to a stronger return on benefits investment.
Identifying Rising-Risk Members Earlier
A retrospective claims analysis provides important insights into trends. However, to identify rising-risk members while early intervention is still possible, it’s necessary to look at current claims, as well.
For example, you can uncover rising-risk members by looking at:
- Claims trends, such as increasing emergency department use, multiple urgent care visits and escalating pharmacy costs
- Clinical data that indicates early problems, such as uncontrolled diabetes, elevated blood pressure, obesity, prediabetes and high cholesterol
- Medication patterns, such as missed refills, new prescriptions for chronic disease and increased polypharmacy
- Behavioral health indicators, such as anxiety, depression and substance use
- Social drivers of health, such as food insecurity, transportation barriers, housing instability and caregiver stress
How Proactive Care Management Changes the Trajectory
Self-insured employer healthcare plans often use traditional care management approaches that concentrate resources on members after a hospitalization or major claim. Proactive care management takes an alternative approach by identifying opportunities for earlier intervention.
- Preventive care supports well-being while supporting early identification of rising-risk members. Through plan design and member education, plans can encourage annual physicals, timely screenings and recommended vaccinations. When potential issues are detected, plans can also encourage follow-up appointments.
- Personalized outreach engages rising-risk members once they’re identified. This can take the form of nurse care managers or health coaches who reach out to members and provide guidance, digital engagement that empowers members to take control of their own health and primary care coordination that reduces the confusion and complexity that can create barriers to care.
- Chronic disease support helps prevent escalation of health issues. Small chronic conditions can lead to more serious and expensive health problems if they are not controlled. Plans can provide support with programs such as diabetes education, nutrition counseling, weight management and hypertension management.
- Behavioral health integration supports well-being. Mental health can affect physical outcomes, and vice versa. For example, a member who is experiencing depression as well as prediabetes may have a higher risk of nonadherence to treatment plans. Early behavioral health support can improve both mental and physical health outcomes.
Technology Makes Early Intervention Possible
Early intervention is increasingly feasible thanks to various technologies.
- Predictive analytics. Self-insured plans have access to a wealth of claims data. This data can power predictive analytics in healthcare to identify members likely to experience increasing utilization, hospitalizationand disease progression.
- AI-assisted risk identification. Care managers can use AI to analyze information and support decision-making. For example, AI can help plans detect care gaps, prioritize outreach and recommend next best actions.
- Integrated data. When data is siloed, it can be difficult to detect trends that span multiple data sets. Integrated data helps plans take a holistic view of trends across claims, pharmacy, lab results, health assessments, wearables and care management documentation.
Building an Effective Rising-Risk Strategy
If your plan currently takes a typical, retrospective approach to cost control, adopting more proactive care management solutions represents a major transformation. Making this transformation successfully may require expanding how your organization identifies and manages risk.
- Invest in continuous risk stratification. Annual reviews are important, but if you want to practice early intervention, they can’t be your sole source of insights. Supplementing annual reviews with more continuous assessment can help plans identify emerging risks as new data becomes available.
- Segment members by need. A proactive approach expands care management beyond members who already require complex care. For example, low-risk members benefit from preventive care and screenings, while rising-risk members may also benefit from education and coaching. High-risk and complex-care members may require additional support, care coordination and guidance. This approach helps ensure members receive support appropriate to their level of need.
- Engage members early. Cancer diagnoses, strokes and heart attacks may be preceded by signals. These signals are your opportunity for early intervention.
- Coordinate across the care continuum. When members struggle to navigate care across multiple providers, confusion and nonadherence can lead to worse outcomes that necessitate more expensive care. Care coordination specialists can encourage collaboration among primary care providers, specialists, behavioral health professionals, pharmacy benefit managers and employee assistance programs.
- Measure success beyond cost. Early intervention and high-cost claim prevention can help plans save hundreds of thousands or even millions of dollars, and plans may see a decrease in hospital admissions and emergency department visits as a result of their efforts. However, it’s often difficult to quantify prevented costs. Plans should consider other metrics that can demonstrate success, such as engagement rates, preventive care completion, medication adherence, chronic disease control and employee satisfaction.
Healthcare cost containment doesn’t have to come at the expense of plan members. With proactive, human-centered care management, self-insured employers can reduce costs by helping members get the right care at the right time. Learn more about ICM’s human-centered approach to medical management.