PART One: The Missing Link to Patient/Member Engagement to Care Management Background
Numerous industries have used risk adjustment models to predict consumer behavior and tailor products based on buying patterns of the individual consumer. The health care industry also uses risk adjustment models for a variety of tasks such as actuarial work, case/disease management, and patient attribution. However, health plans and providers have traditionally focused on employer groups and population health, not the individual consumer. With the employer-capital role reductions on the horizon, health plans and providers are facing new competition with sophisticated marketing skills that know how to work with and deliver to the individual consumer market.
As such, healthcare risk adjustment models do not always completely and accurately predict valid health care expenditures and patient/member market spend. The risk models also do not factor additional variables that contribute to patient/member health outcomes or costs of care such as socio-economic disparities, benefit plan designs, patient non-compliance with treatment plans, or unresponsiveness to treatment.
Current risk adjustment models and implementation approaches do not have the ability to:
- Sift through hundreds of thousands of health risk records, prior engagement decisions/outcomes, patient satisfaction data, etc., and
- Take immediate action as a result of outcomes and care engagement that result in a return on investment for the healthcare entity and the patient/member.
Key questions are often overlooked items such as:
- How do we handle and prioritize patients/members with multiple conditions?
- How do you handle products with benefit carve outs and opt-in/opt-out mandates?
- How do we interact with populations based on risk scores, motivation to change, and preferred outreach mediums?
- How is engagement modified based on a patient’s/member’s willingness and readiness to engage?
- How are patients/members handled whom have already been engaged at some point in time? When is the right time to engage? And, is the engagement different based on previous interactions?
- How does patient/member knowledge of condition affect goal compliance and/or engagement success?
- What volumes of members/patients can be handled with current capacity of systems/staff or are required to be handled based on service level of agreements and statutory mandates?
In short, information presented in risk models and deliverable capabilities need to be based on value to the patient/member (e.g., quality of life, rapid turnaround, low cost) and the return to the organization (e.g., revenue growth, community service, quality outcomes, administrative savings) to meet the demands of the new emerging consumer-centric market. Models using other health data, such as lab results or survey data on self-reported chronic disease or functional status represent the next exciting frontier for predictive modeling.
SDLC Partners, a business technology consulting firm with a focus in healthcare, has developed a framework called Member-Centric Care Optimization™ (MCCO™) to study and improve upon some of the market’s disparities. MCCO™ is part of this new frontier in stratification and automated delivery through the further refining of health risk data, benefit design data and consumer behavior data, socioeconomic data, and patient non-compliance and satisfaction to return the most value out of a care engagement. The framework is described in more detail below:
SDLC Partners – Member-Centric Care Optimization™
MCCO™ – FACTORS
- Healthcare Cost & Risk: Health and associated care gaps of certain populations or individuals
- Consumer Preferences: How and when a customer expects to be serviced
- Delivery Capabilities: Ability of an organization to service the need of individual consumers with the right internal and services processes that can adapt rapidly to changes in the market
- Environmental Factors & Outcomes: The environment and socio-economic factors that affect space and time across attributed patient/member populations
- Speed to Market: Provide products and capabilities to address the individual and populations before competitors and new market entrants
- Clinical Satisfaction: Deliver on evidence-based guidelines and consumer quality of life attributes with the most appropriate clinical and wellness services
- Cost Reduction: Bend the cost curve in medical spend and deliver engagement services for the individual consumer
- Financial Performance: Execute on individual consumer services that grow the top line while maintaining financial margins for the organization
MCCO™ – CAPABILITIES
- Health Risk & Cost Stratification: Ability to use data to predict health risk and cost based on claims history, health risk assessments, and pharmacy data. There are many robust risk and cost stratification models that exist in the market that can be utilized from episode-based, conditionbased, and/or population-based stratification approaches (e.g., Diagnostic Cost Groups (DxCGs), Episode Risk Groups, Medstat Episode Groups, Adjusted Clinical Groups, etc.).
- Market Segmentation: Ability to use market segmentation data such as a consumer’s readiness and willingness to engage and preferred means and context of outreach to increase use and satisfaction with services/products. This is often located in a retail platform or customer relationship management (CRM) system.
- Health Literacy: Measuring a patient’s/member’s understanding of actions needed to improve a condition to evaluate his/her readiness to change. This component is often overlooked but may be located in a care management or CRM system.
- Automated & Predictable Value Delivery: Use of automated systems, health risk/cost data, and market segmentation data to automatically recommend task fulfillment and outreach activities that produce value for the individual patient/member and return for the supporting healthcare entity. A portion of this functionality is available in care management, identification and stratification, and business process management systems. A comprehensive solution, however, often needs to be developed to address how the healthcare entity wants to specifically engage based on their consumers and offerings within the market.
- Geographic Information System (GIS): This includes observation of health risk/cost and market segmentation data by space and time to observe patterns of outreach effectiveness across geographies to fine tune programs that meet the needs of the specific region or consumer. This functionality and the corresponding value of measuring outcomes, satisfaction, understanding/readiness, engagement, etc., over space and time is not utilized in the industry to improve health outcomes of our communities.
- Bend the Cost Curve: Increased utilization of preventative wellness programs by proactively identifying gaps-in-care and ensuring care plan compliance for chronic conditions
- Improve Operating Margin: Increased productivity and reduced clinical variation through streamlined care delivery by allocating scarce capital resources to the right services at the right time
- Grow Revenue & Innovate: Increased healthcare product and service market penetration by having the ability to observe member health and service performance across space and time as well as the ability to adjust those products/services in near real-time to meet patient/member needs
MCCO™ provides the missing link in risk stratification and engagement execution by going beyond gaps in- care and cost triggers to include consumer behavioral/preference, outreach effectiveness, and volume/capacity data to augment care plan compliance using the most efficient and effective means necessary (e.g. web/fulfillment, nurse, integrated voice response, etc.).
To learn more about how MCCO™ works, please read Part 2 of our series.