Just like trends in fashion, healthcare practices evolve over time.
While some trends fade away, enduring approaches like Care Management (CM)—sometimes called Clinical Care Management—continue to adapt and remain relevant. Each time healthcare numbers rise, another wave of interest is focused on CM’s cost-saving efforts.
How do you know if this tool is the right choice for your clients?
It’s essential to grasp what CM entails, the advantages it offers, and the key features to consider when evaluating its effectiveness.
What is Care Management (CM)?
Care Management is all about taking a proactive and personalized approach to cater to members with intricate health needs.
When delivered through a Third-Party Administrator (TPA), CM offers tailored services aimed at enhancing member outcomes, cutting down healthcare expenses, and boosting member satisfaction.
This proactive and member-centric method not only focuses on improving health results, decreasing hospital visits, and reducing overall healthcare costs but also promises a more efficient and effective healthcare system.
TPAs like Personify Health, who provide CM, boast a dedicated team comprising healthcare experts like nurses, social workers, care coordinators, and, in the case of Personify Health, an in-house medical director. Together, this team collaborates to deliver individualized care to members.
CM teams utilize evidence-based care models and clinical protocols to ensure that members receive the medical attention and support they need.
Members engage with their assigned care advocate through various resources such as chronic disease management, behavioral health support, health coaching, maternity care, significant case management, and utilization review to craft a care plan tailored to address their medical, social, and emotional requirements. These care plans involve organizing healthcare services, providing education and support to members and their families, and tracking progress over time.
The journey of CM commences by identifying members with complex health needs, including those with multiple chronic conditions, at risk of hospitalization, or requiring continuous medical care. Subsequently, a dedicated care team is established to ensure these members receive comprehensive care and assistance.
Why should you have a Care Management (CM) program?
CM is one more way to show your employees you have their back.
It offers numerous benefits for members with complex medical needs, such as personalized care and support that can prevent complications, reduce hospitalizations, and ensure timely and appropriate medical attention.
One great advantage of CM is that it takes a proactive approach to healthcare, whereas conventional practices wait for members to fall sick or require hospitalization. CM focuses on identifying potential health risks and addressing them before they escalate into serious complications. This proactive strategy can significantly improve overall health outcomes, reduce healthcare costs, and optimize care quality for members and the employee population.
What should you look for in a Care Management (CM) program?
When evaluating a CM program through a TPA, there are a few critical factors to consider.
1. Evidence-based and data-driven. Evidence-based care models and clinical protocols ensure members receive appropriate medical attention and support. These care plans should align with the latest clinical guidelines and best practices.
2. Patient-centered and personalized. A good CM program will use risk stratification tools to identify potential high-risk patients. This will alert the care team to members at risk for adverse health outcomes so they can provide patient education and support services. Early identification ensures effective communication and collaboration among members, their families, and healthcare providers.
3. Comprehensive. Look for a team of healthcare professionals with extensive experience managing complex medical conditions. You want a team versed in more than diabetes and high blood pressure (those are important, too!). Your CM team should be familiar with transplants, maternity management, and cancer care and could also walk members through an unexpected ER visit.
4. Robust data analytics. Never sacrifice your data! A solid CM program should have data analytics and reporting capabilities [MAM1] to track patient outcomes, monitor program effectiveness, and identify opportunities for improvement. A continuous quality improvement process evaluates program effectiveness, identifies areas for improvement, and guides you on implementing necessary changes.
5. External validation. Your partner should offer actuarial validation[MAM2] to evaluate the financial impact and cost-effectiveness of a CM program. A professional and unbiased validation will provide you with transparency and insights into the program’s financial implications.
The actuarial validation process should consider the specific nature of the population reviewed, adjusting for risk and geography, and assess the program’s cost savings, impact on utilization, baseline healthcare costs, and health outcome improvements.
Why should you partner with your TPA for Care Management (CM)?
Partnering with a TPA for CM services is like getting a free upgrade on an international flight.
The experience and advantage offered by a TPA is something you may not have noticed you were missing until you experienced it for the first time. And unlike first class, it won’t break the bank.
The advantages of a TPA include improved healthcare cost management, enhanced employee health outcomes, increased employee satisfaction, access to specialized healthcare expertise, tailored customization to meet specific employer needs, and robust data analytics and reporting capabilities.
Having a CM program directly integrated within the TPA’s infrastructure brings about a tightly knit system, efficient processes, and enhanced customization.
At Personify Health, for example, we capitalize on our existing infrastructure, technology, and established relationships with healthcare providers to streamline the implementation and delivery of CM services. This allows us to tailor the program closely to existing services, such as utilization management and claims administration, giving us complete control over the program.
Our comprehensive reporting and analytics further integrate CM data with other healthcare data, providing a comprehensive understanding of employee health. This collaborative approach to plan design ensures optimized engagement, reportability, and customization that align with the specific population we serve.
Ultimately, the decision to integrate CM with your TPA or an outside vendor will depend on several factors, such as the TPA’s capabilities, your specific requirements, and the desired level of integration and customization. It’s crucial to have transparent discussions with your chosen TPA to understand their abilities and how they can best support your CM needs.
What can you expect from a Care Management (CM) program?
When it comes to investing in employee health, brokers and employers should expect a CM program that significantly enhances the health and well-being of their workforce.
At Personify Health, we recognize the connection between employee health and productivity. We value the role an effective CM program plays in promoting a healthier workforce – leading to reduced absenteeism and substantial savings on healthcare costs.
You should expect a CM program that yields tangible benefits while ensuring high engagement rates, resulting in a happier, healthier, and more productive workforce.
From the employee’s viewpoint, a CM program should provide a personalized and attentive healthcare experience tailored to individual needs. This approach enables improved health outcomes and reduces the incidence of chronic diseases and complications.
Additionally, our CM program provides improved access to healthcare services, bridging gaps in care and ensuring timely interventions. Most importantly, our enrolled members can relax knowing that their health is being actively managed and monitored, promoting invaluable peace of mind.
In essence, a CM program creates a symbiotic relationship between employers and employees.
Employers can realize cost savings and productivity gains, and employees benefit from personalized care and improved health outcomes. Our focus on outcomes and evidence-based programs ensures that your investment in employee health will deliver the desired financial returns as well as a happier, healthier, and more productive workforce.
What does a Successful Care Management (CM) Program Look Like?
In the world of healthcare, trends come and go, but their success ultimately hinges on delivering tangible results.
Achieving a delicate balance between fostering overall population health and bolstering financial wellness isn’t always simple. However, CM emerges as a pivotal solution where both members and health plans reap significant benefits.
At Personify Health, our CM program has showcased remarkable outcomes. By guiding members with chronic conditions towards healthier habits and empowering them to make sustainable health decisions, we minimized acute incidents and readmissions.
In 2024, an external analysis of Personify Health data comparing book of business data to a similar demographic revealed surprising results.
- 27% lower outpatient costs
- 80% lower out-of-network utilization
- 14% savings in high-cost claimants
- 17% decrease in emergency room costs
- 50% lower NICU costs
All these decreases translate to $63.58 saved per employee per month (PEPM).
Studies by McKinsey highlight that payers can potentially achieve a two-to-one (2:1+) ROI by expanding their care management tools. This means for every $1 invested, plans could realize a $2 return, all while enriching the healthcare experience for members.
Based on the proven results at Personify Health, CM emerges as a formidable solution for managing costs effectively.
Entrusting your benefits plan to Personify Health leverages our wealth of knowledge amassed over decades. While industry trends may ebb and flow, our commitment to data-driven practices ensures that effective plan management and impactful cost-saving strategies like CM remain enduring solutions, far from being mere passing fads.