The importance of care management in managing high-cost claims

There’s a reason that managing high-cost claimants is the top priority for employer health plan sponsors: half of their health plan cost is driven by a small fraction of plan members with serious medical issues. Further, high-cost claims are rising in both frequency and average cost, for reasons that include the rapid introduction of expensive new specialty medications and the alarming trend of chronic diseases manifesting at younger ages.
Yet many employers lack a clear understanding of what effective clinical care management entails – what exactly a nurse care manager does and how it reduces cost. Let’s consider the example of a member who winds up in the ER with hypoglycemia. One scenario is that he is stabilized and sent home, until the next episode brings him back. But in another scenario, a care management nurse makes contact and learns that the member doesn’t test his glucose regularly because of the cost and a glucometer that is difficult to use. She educates him about the diabetes program offered by his employer, which comes with unlimited free test strips and a user-friendly glucometer. She connects him with a dietitian who can assist with a customized eating plan. And she connects with him regularly to check in, monitor progress, and help him prepare for doctor appointments. Ideally, that first trip to the ER was his last.
What else does a care manager do? Patients with chronic conditions frequently see a number of specialists, which – without the help of a care manager – can lead to miscommunication and medication errors. Post-treatment follow-up is another important aspect of the care manager’s role. Studies show that only about 40% of patients retain post-discharge instructions from hospitals; effective care management reduces the likelihood of complications and readmissions.
The need for oversight
While the need for care management is clear, it’s also clear that all care management is not the same. Across the sources of care management – medical insurance carriers, pharmacy benefit managers, and specialty vendors – there can be critical differences in the level of service provided. It’s also challenging to evaluate performance, since what’s being measured is cost that was prevented.
That’s why third-party oversight can be so valuable. For example, a comprehensive review might reveal ineffective management of prescription drugs, or that outreach efforts are limited to only the most catastrophic cases. It is important for employers to evaluate care management programs to ensure they are performing as intended – providing value to members and meeting the employer’s financial objectives.
Effective care management should include:
Medication reconciliation. The nurse care manager reviews the member’s prescriptions using data from medical and pharmacy plans and any point solutions and engages a clinical pharmacist to identify any potential adverse drug interactions and complications. If necessary, they work with the prescribing providers to make and ensure the member understands the regimen.
Proactive outreach. While some programs limit outreach to members exceeding a claims dollar threshold or those discharged from the hospital, the best programs will proactively identify and engage high-risk members to coordinate care, close care gaps, improve health outcomes
Behavioral health support. Serious medical conditions can involve fear, uncertainty, pain and financial stress for the patient. Behavioral health support can help patients better cope with a difficult situation and even improve health outcomes.
Utilization of point solutions. Where patients have access to point solutions for managing chronic conditions, effective care management ensures that patients are aware of these resources.
Questions employers should ask
Here are some questions employers can consider asking their vendor partners to ensure they are receiving the best possible care management services:
- What specific metrics do you use to measure the effectiveness of your care management program?
- How do you ensure that all patients, not just those with catastrophic events, receive follow-up care?
- Can you provide examples of how your care management team has successfully managed complex cases?
- What processes do you have in place for medication reconciliation and coordination among multiple providers?
- How do you incorporate behavioral health support into your care management services?
Effective care management is essential to manage high-cost claims and ensuring that employees receive the care they need. Employers must prioritize oversight and actively engage with their carriers to understand the level of service being provided. By asking the right questions and seeking third-party evaluations, organizations can enhance their care management programs, ultimately leading to better health outcomes for their employees and reduced costs for the organization.
Kelsie Stott is the product leader for Mercer Health Advantage, a high-touch clinical care management program designed to support health plan members who have complex health conditions.