5 value drivers health plans realize when identifying and managing their most complex cases with the right partner

June 15, 2018

By Chad Baugh, Vice President and General Manager, Complex Case Management, Teladoc

Although it is generally accepted that 5 percent of the population drives 50 percent of healthcare costs, pinpointing the cases most responsible and properly managing them can be tricky.

Time constraints, medical information fragmentation, and dissemination of the latest evidence-based information are all obstacles. Therefore, it’s important for health plans to work with partners that can help identify their most complex and costly cases, ensure they’re on the best possible path―and if not, help to course-correct―as early as possible. In some cases, these patients can be identified even before they show up on the health plan’s radar.

An integrated program that matches cases with the right application of expertise and resources can help health plans improve outcomes and care quality while reducing costs and strengthening payer-provider-member relationships.

Here are five key takeaways from Teladoc’s Health Plan Claims Analysis Study, a comprehensive, claims-based study performed with a large health plan that utilized Teladoc’s Complex Case Consult service. This service augments a health plan’s case management strategy by providing comprehensive clinical case reviews by top expert specialists for members with costly, highly complex cases.

Improve outcomes

In 87 percent of cases reviewed, patients adhered to the expert recommendations, with a per-case savings of approximately $39,000. When patients did not follow the recommendations, costs were five times greater. Identifying the right cases, assuring accurate diagnoses and treatment plans, and working with members to implement the expert’s recommendations improves not only patient quality of life but also reduces the health plan’s costs.

Identify and intervene early

Complex cases can be identified through claims data and sometimes through clinical data, but success increases when case managers have been well-trained and partner with the right clinical resources to spot trends. Signs include cost escalations, multiple emergency room visits, and the use of multiple drugs in the same therapeutic class. Certain conditions, such as irritable bowel syndrome and diabetes, raise the risk for patients to land in the complex-care category.

Reduce expensive, unnecessary, and ineffective care

Finding the right cases at the right time for an expert medical review can lead to lower overall utilization of healthcare services by reducing unnecessary tests and procedures. The study shows that a Complex Case Consult can reduce utilization of acute-care and high-cost settings by between 25 percent and 34 percent. What’s more, health plans realized 97 percent of their savings attributed to this reduction within the first six months of the expert case review.

Strengthen payer-provider integration

Complex cases can challenge even the most qualified and competent physician. Augmenting case management with an expert medical review program for complex cases should be part of the case management toolbox for every health plan. A clinically collaborative partnership can expand the treating team’s capabilities to ensure every member can make well-informed medical decisions to receive the best possible care.

Lower drug spending

Many patients with complex cases are taking expensive medications to treat their conditions. Spending on specialty drugs increased by $54 billion over the past five years, accounting for 73 percent of all medicine spending growth.1 An expert medical review for a member with a complex case that results in just a slight adjustment to a diagnosis or treatment plan may also be accompanied by a recommendation for lower-cost medications with similar efficacies. This can improve the outcome for the member and result in significant savings for a health plan.

Find out how health plans are reducing costs and improving outcomes for their complex cases by downloading Teladoc’s Executive Summary: Health Plan Claims Analysis Study.

1. The Facts About Rising Prescription Drug Costs,” http://www.csrxp.org/wp-content/uploads/2016/04/CSRxP_Facts-of-Rising-Rx-Prices.pdf

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