Promise of VBC: The imperative of care management programs to focus on low-risk members

Preventive care delivery is one of the inalienable levers of value-based care (VBC). With the increasing VBC adoption, many healthcare payers have been offering care management programs that aim to promote overall member wellness by managing members’ medical conditions and preventing progression of chronic diseases.

At the outset, both members and payers have aligned incentives vis-à-vis care management programs, as these programs lead to improved member health outcomes and thereby reduced medical expenses. However, a closer examination of these programs reveals that payers’ financial incentives may not always align with the health outcome incentives of low-risk members. Failing to address this misalignment can negatively impact members’ health and increase costs. 

Current Payer-Led Care Management Approach

Payers' care management programs typically rely on predictive risk stratification models to categorize members into high to low risk categories based on their likelihood of experiencing severe adverse clinical outcomes (e.g., hospitalization due to chronic heart failure). High-risk members, compared to low-risk members, are at a greater peril of experiencing adverse clinical outcomes in the immediate future due to factors such as advanced stage of their disease states, comorbidities, and less advantageous socio-economic conditions. While payers engage with members across all the risk categories, their interaction with low-risk members is generally less frequent and less hands-on compared to high-risk members. 

Payers prioritize frequent and intensive engagement with high-risk members for good reason. Research has consistently shown that high-risk members tend to be super-utilizers of advanced and costly medical services, driving up healthcare expenses. By actively engaging these members, payers aim to prevent their conditions from worsening, leading to improved healthcare outcomes and reduced costs. Additionally, since these preventable medical expenses would have incurred in the short term, payers are able to easily measure and demonstrate a positive return on investment (ROI) for their initiatives. 

Comparatively, care management initiatives for low-risk members do not always offer the same positive ROI for payers. This is because low-risk members typically have low-to-no medical expenses related to their chronic diseases in the near term, and are likely to incur expensive medical costs after they have left their current payer. As a result, payers can be financially less motivated to invest heavily in the care of these members, especially for prevention of the chronic disease advancement. 

However, this approach of less frequent care of low-risk members defeats the overall purpose of VBC, as it incentivizes investing intensely in preventative care only ‘after’ the members have reached high-risk stages. Collectively, at the industry level, this approach hurts not only population health outcomes but also increases the total healthcare costs. To avoid this, payers need to find financially feasible ways to effectively engage and prevent health risk in the members when they are at low-to-no risk stages. 

Potential solutions

Below are some of the ways payers can timely and effectively engage low-risk members, without significantly increasing their operational expenses and maintaining a positive ROI. 

Prioritizing highly impactable care gaps

Payers can consider prioritizing and targeting the care gaps which have high potential to adversely impact a member’s health, if not closed in a timely manner. For example, a payer might consider reaching out to a member who has not visited their primary care provider for a given stretch of time and help them schedule the appointment. This is because primary care providers are best positioned to play the role of a quarterback when it comes to managing the health of a low-risk member. Similarly, a low-risk member with a chronic condition should be reached out to, if they have not visited their relevant specialist for a given amount of time. 

Exploring low-cost outreach methods to close care gaps

Care management programs are run by care management teams, which are typically composed of nurses, pharmacists, and social workers, amongst others. The key operational expense incurred by these teams is the time utilized to implement call-based outreach which includes call preparation, call duration, and post-call documentation. Payers bear these operational costs to incur savings by potentially preventing a medical event, and as such savings are typically neither imminent nor certain for low-risk members, incurring call-related costs adversely impacts payers’ ROI. Below are some outreach strategies that can help payers minimize such costs.  

Utilizing digital outreach: Payers can leverage digital outreach, such as text messages or emails, to engage low-risk members cost-effectively. Digital outreach saves the care management team's time and can be more convenient for members. Moreover, with the increasing preference for digital solutions among healthcare consumers, this approach can be more appealing to low-risk members.

Bundling gaps in care: Payers can bundle care gaps together and address them during a single outreach. This approach ensures that outreach is still made even if there are not enough individual gaps to justify a separate call. This approach would require payers to determine the minimum number of gaps that need to bundle before making an outreach, types of such gaps, and maximum waiting period.

Closing less-urgent gaps without triggering an exclusive outreach: Payers can consider certain gaps as "informational only," i.e., gaps that do not trigger exclusive call outreach but are addressed during scheduled routine calls. This approach can help reduce costs while still providing essential information to low-risk members. A minimum scheduled call cadence would be required to be maintained to ensure regular engagement.

Facilitating tie-ups with community organizations 

Proactively facilitating connections between low-risk members and community-based or social welfare organizations can significantly enhance members’ physical and emotional well-being. These organizations, in addition to being readily accessible and empathetic caregivers, play a crucial role in educating low-risk members about the significance of adopting healthy habits, undergoing preventive care measures, and adhering to regular screenings. By leveraging these community resources, payers can help their members avoid unnecessary medical costs associated with untreated or undiagnosed conditions. 

Leveraging AI 

As AI solutions become more nuanced and regulated, they can be leveraged for administrative tasks (e.g., call documentation), allowing care management teams to reallocate their time towards engaging more members. 

Contextual Considerations to Optimize the Above Solutions 

Timely data access, interoperability, and digital methods are crucial for effective decision-making and care coordination. Additionally, robust member retention strategies can help prevent low-risk members from leaving for competitors and maximize the benefits of payers’ efforts. 

Conclusion

While the fundamental premise of VBC is to align healthcare stakeholders’ financial incentives with population health outcomes, sometimes these incentives diverge. While optimizing health outcomes is paramount, it must be done in a financially feasible manner to ensure sustainability of the entire ecosystem. This is where the need for innovative and resourceful solutions becomes crucial. By prioritizing care gaps, utilizing cost-effective outreach methods, fostering community ties, and leveraging AI, payers can achieve a positive ROI while ensuring that low-risk members receive necessary care to prevent future health complications.

Pankhuri Sharma is Strategy & Operations Leader at Humana.

The views expressed in this opinion are those of the author and do not necessarily reflect the official policy or position of Humana.

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