As growth in the Medicare Advantage markets continue, the investment to gain better insight also continues. Special focus is being placed on risk stratification, early intervention programs targeting certain chronic conditions, and product strategies to attract and retain members. Interestingly, product strategies added to attract members may not lend themselves towards contributing to improving member’s health or costs of care unless effective data analytics is applied.
Convey has begun to use analytics by combining supplemental benefit data, claims, and enrollment information to better understand member behavior in order to strengthen the effectiveness of popular supplemental benefits programs. Convey believes there are opportunities to engage members holistically across clinical, quality, and by aligning behaviors with health plan clinical programs tailored to improve outcomes. To validate this belief, we sought to analyze our over-the-counter (OTC) benefit program data with a clinical and risk perspective to better understand and identify opportunities.
The findings were extremely insightful as to behaviors and trends of these programs and the effects these programs are having on certain member cohorts. In some cases, certain broadly offered supplemental benefits resulted in a negative impact to member’s health and, ultimately, the health plan’s medical expenses. An assumption from the analysis is that health plans are simply adding supplemental benefits as a competitive tool to attract and retain members, but are not yet looking at the impact these programs are having on their member’s health or on the ability these programs can have to improve revenue.
In most cases, plans have started to conduct targeted outreach to specific populations to introduce ways to improve the member’s health. Convey’s approach was to analyze the data, then provide simple ways to introduce solutions to targeted populations reducing the overall efforts from the health plan. In Convey’s analytics, we established clinical and risk profiles using data sources that are already available. We looked at medical costs, pharmacy costs, ER visits, inpatient admissions and readmissions, and incorporated the CMS risk score using the most current Convey-implemented CMS risk adjustment model for the Medicare Advantage population.
The results of our finding showed that members using the Convey OTC supplemental benefits program often have a higher clinical and risk profile, but often show better trend over a time for many member cohorts and conditions. The results also showed a sizeable overlap between OTC population and focus cohorts for key health plan programs, including risk adjustment and Stars. As a result, Convey determined there are tangible use cases and opportunities for targeted interventions.
These use cases allow us to help the health plan target certain cohorts with the potential to improve their care or reduce the negative effects of the supplemental benefits. As an example, for fall prevention, Convey could identify members with a prior fall, or at risk for a fall, and who have not yet purchased fall prevention products. Through alerts, Convey’s advocates can recommend fall prevention products to these members to prevent injury and extended medical expenses.
Further, members suspected to have diabetes and who may purchase diabetes management products (e.g., diabetic socks, alcohol prep pads, and diabetic foot creams) could be directed to diabetes management programs offered by the health plan. Convey’s analytics can support properly coding these members along with the opportunity for prospective interventions in coordination with the health plan’s already in-place diabetes outreach activities.
By combining Convey’s analytics with the health plan’s already deployed supplemental benefits programs (offered by Convey) additional opportunities are available including identifying coding gaps in risk adjustment. Similar to the above example, we recognize that a health plan’s overall population may be suspected to have an undocumented risk adjustment condition. Knowing this, Convey’s analytics can evaluate members that used their OTC benefit and surface undocumented risk adjustment conditions, resulting in additional revenue opportunities for the health plan.
Convey’s analytics provide a clear opportunity to leverage the ongoing engagement that occurs between the Convey advocates and the health plan members to address and close these gaps, which should yield tangible revenue improvements to the plan. In some instances, Convey interacts with plan members more frequently than the health plan themselves. Because these interactions are typically positive, Convey can more easily introduce certain solutions to these targeted populations. In effect, this approach can be a seamless interaction with the member as opposed to a more direct or “cold” outreach.
Convey’s analytics demonstrated that there is an opportunity to include quality, clinical, gaps in care, and social determinants of health (SDoH) related programs to maximize existing member touch points and institute an integrated engagement and intervention strategy that can result in valuable financial and clinical improvements.