Is Your Care Management Program Producing Results?

Healthcare expenses continue to rise for employers in all sectors, driven primarily by the increase in chronic diseases. Unaddressed chronic conditions cost employers more than $36 billion annually in the form of reduced productivity, but the total economic impact is estimated at $1 trillion each year.1,2 In 2021, the average cost to provide family coverage was $16,253, a 47% increase over the previous ten years.3

A care-management program is vital to containing coverage costs, but not all programs deliver positive results.

The complexity of the healthcare system, particularly health insurance, is challenging to understand. Many individuals put off care due to out-of-pocket costs or because they simply don’t know how to better manage their health. When this happens, chronic conditions can worsen, leading to poorer outcomes and higher healthcare costs. The best approach to addressing these issues is to provide high-risk employees with supportive programs that can help them better understand the impact of their chronic conditions and that give them the tools to better navigate and utilize available resources.

Misaligned Incentives

Many ASOs and TPAs offer a care-management program as part of a bundled benefits program. But programs that are part of a larger offering can be nearly impossible to carve out in a way that enables the accurate measurement of results. Many ASOs and TPAs use these programs as a loss leader, meaning they don’t always have the employer’s best interests in mind. While they may show positive response rates to outreach emails or tout the number of employees who engage with the program, they cannot show genuine year-over-year return on investment.

A More Effective Program

Misaligned ASO and TPA incentives are the reason many large companies are choosing stand-alone care management programs that focus solely on getting results. These programs can isolate care-management expenses, including coordination of services and management of high-risk employees, so they’re able to track outcomes to the specific program elements. This level of detailed analysis provides transparency in ways bundled care-management programs cannot.

six elements to look for when choosing a stand-alone care management partner

To determine the actual return on investment, program providers should be able to conduct a detailed cost-benefit analysis on the program alone, not inclusive of other services. Calculating the return on a portion of a bundled program will not provide an accurate picture of ROI. Vendors should also be able to isolate any provider rate changes so that employers can see how the changes may have impacted the care-management program ROI.

Distributing pamphlets, sending emails, and conducting benefits meetings should not be counted as engagement in a vendor’s ROI analysis. Genuine engagement should be based solely on employee interest and activities.

The best care-management partners have skin in the game, which means they will do all they can to create a successful program for the employer. This includes full transparency and sharing information with the employer’s stop-loss carrier. It’s a win-win for both the employer and the partner.

Multiple assessment models can be used to identify employees at greatest risk of poor outcomes and high costs. This is why the most effective vendors will be able to perform both retrospective and prospective analyses to identify and target these employees. Their outreach should be proactive and hyper-focused on engaging these specific employees.

Most chronic conditions are related to lifestyle choices, which means an effective care-management program will have a solid educational component. While acute-event recovery should be a part of the program, it must go further to help employees make sustainable lifestyle improvements.

Employers typically have a varied population with varying health needs. They should look for care-management vendors that will customize solutions to an employer’s unique population, goals, and requirements. A one-size-fits-all approach should be a red flag that a vendor is inflexible and may not have the employer’s best interests at heart.

A Change in the Right Direction

Healthcare expenses are unreasonably high for various reasons, but it is clear that chronic conditions play a significant role. A care-management program is vital to containing coverage costs, but not all programs deliver positive results. Employers should take this opportunity to re-evaluate their current offering and determine if a carved-out solution may make more economic sense for their organization.


Let’s Talk
Share This Page