By DARREN REYNOLDS
As healthcare costs continue to rise in the United States, companies are scrambling to find solutions that will drive down expenses without putting employee populations at risk. More than ever, industries are moving toward building high performance health plans, utilizing community-based healthcare models, and turning their attention to Third Party Administrators (TPAs) who can offer more than claims management.
The need for the healthcare industry to "bend the trend" and get these costs under control for its own employee populations has never been more important. With more than 100 rural community hospital closures across the U.S. since 2010, it is easy to see the crippling effects these costs have had on the industry's ability to deliver critical care to the communities it serves.
Here's how it works
Traditionally, TPAs manage and process claims for clients. It's the core of what we do, but over time it has become clear that in order to truly help our clients, we need to do more. It has become the responsibility of TPAs to turn an employer's health insurance program from an operating expense into a performing asset.
Over the two decades we have been working within the healthcare system environment, we have been exposed to population health management in its original form. We have also been able to work with scores of data in the process. We began to question - are there services that can be provided to close the gap in increasing claims cost? Is there a way to consolidate this data and analyze it in a way that could help healthcare systems reduce their costs by keeping their employees healthier--thereby reducing claims?
Fifteen years ago, the data that TPAs had access to was simple, static reports. The reports made it possible to tell clients how much money they spent, but we could not identify where costs were increasing. For example, was it attributable the top 10 chronic patients in their employee mix, or were there significant gaps in care?
We discovered that by having better data and using data as a tool, clients could better understand the story behind their top patients, and in many cases isolate what was driving up their individual healthcare costs.
Over the last decade, our industry has been able to "bend the trend" and use comprehensive data to decrease a company's overall healthcare costs while at the same time providing better, more meaningful care. Now, we are able to take medical data and claim data, including biometric and phlebotomy results, and embed them in a tool that provides a HIPAA-compliant, population health virtual medical record. This allows an employer's partner health system or case management vendor to quickly access a member's entire health status, gaps in care and willingness to change care record, at the touch of a button.
Knowledge is power
Healthcare costs are typically the second or third largest expense in most companies, and entrepreneurial employers today are participating more than ever in the management of their own health plans. TPAs who partner with healthcare systems to help manage employee populations for those systems, or the communities they serve, will be able to provide valuable information to their clients. Many insurance carriers are not set up to share data with hospital systems, but to be able to do that in a scalable, accessible manner makes an important difference in the level of service and engagement a TPA can offer.
Using this "data first approach" helps healthcare decision makers identify gaps in an employee's care and increase important preventative care methods such as screenings and checkups to keep employee populations healthier and shrink long term healthcare costs.
Today, these tools can predict healthcare costs to a 90 percent accuracy rate. In systems with two years of data, TPAs can share - down to the "bellybutton level" - what each employee is expected to incur in healthcare costs over the next 12 months. It allows employers to identify claim issues and members whose healthcare costs may be significantly higher than the standard. Then, we can not only try to find solutions to manage those higher costs through preventive care but help identify and develop programs that encourage those individuals to lead a healthier life.
Many TPAs have access to this type of information. The value however, lies in how it is analyzed and packaged for clients. Employers should be asking their TPA what resources they have and if those tools can better help manage their healthcare costs. Is your TPA helping you develop a high-performance health plan? Just processing claims alone is no longer enough.
To make change, we need to impact utilization and intensity within a population. Using this data is a huge step. Using metrics just as you would in other aspects of your business, will help control costs and provide a happier, healthier workforce.
Darren Reynolds is president of Consociate Health, an innovator in integrating population health analytics with health care systems for the management of their employee populations. They integrate data and tools into health care systems' Accountable Care Organizations (ACO's), Clinically Integrated Networks, wellness programs and direct to employer initiatives. The deployment and integration of data and these support tools in improving the health of the communities they serve was a key factor in earning this award. For more information visit https://consociatehealth.com/