Clinical Integration

With medical and pharmacy costs continuing to rise, the focus on the cost of employee health benefits is understandable.

But increasingly, sophisticated employers and their advisers are looking beyond line item costs, and concentrating on improved employee health, absence, disability and presenteeism outcomes.

By analyzing available information across a spectrum of benefit products and services — medical, disability, behavioral and pharmacy — a health benefits carrier can see the individual member as a whole. This is known as clinical integration.

“Clinical integration allows us to have an opportunity to use clinical information to identify people who are most at risk from health conditions,” says Mark Hanrahan, vice president of sales and service for the Aetna’s north central west region.

Smart Business spoke with Hanrahan about how clinical integration can help employers get the most from their health care benefits investments.

How does clinical integration work?
Medical, prescription, dental and other available information is integrated in one place in order to assess intervention opportunities to improve enrollees’ health, which may prevent or mitigate work absence. The various disciplines — primary care physicians, behavioral health experts, pharmacists, disease management and disability management staff — all work in concert to create the opportunity for better health outcomes as well as provide enrollees with a more coordinated experience.

It’s looking at a person’s health care needs as a whole rather than looking at their health problems in ‘silos.’

How can clinical integration increase the total value of investments in health benefits?
There are four essential components of a clinical integration offering. The first is the integration of health and productivity data. For example, a health plan will look at its member data to try to identify those who may need intervention by a case manager.

The second is a proactive engagement process. That is, if you have both health and disability management data available, you can initiate an outreach to those members who could benefit from risk-reducing programs.

This leads to a third component which is integrated care management. That could include identifying physician-prescribed individual care plans and tracking the member’s progress under that plan. And the last component is to measure your progress.

Can you explain how looking at a person as a whole may positively impact their health?
Your primary care physician understands that all aspects of your health — physical, dental and behavioral — are intricately connected. Medical science verifies those connections and explains them more fully every day. We know enough to appreciate that medical care should be approached holistically.

But even though a whole-person approach to care makes perfect sense, it’s not always easy to achieve, in part because of the way our medical system works, and in part because of the way most benefit plans are designed. Through clinical integration, which connects a member’s health data, evidence-based medicine and a health plan’s clinical expertise across product lines, a health insurer can bridge together pertinent details about member health, and act to see that those needs are addressed.

By integrating health benefits data, do employers benefit from healthier employees?
We have found that there is evidence that supports a direct correlation between health and productivity outcomes. For example, in an analysis of 50,000 member with fully-integrated medical, pharmacy and disease-management benefits, integrated plan members experienced:

  • 35 percent fewer ER visits for asthma, diabetes and heart failure
  • 34 percent fewer hospital administrations for asthma, diabetes and heart failure
  • 15 percent lower medical costs for asthma, diabetes and heart failure
  • 25 percent more people were identified as possibly having a disease — 33 days earlier than with stand-alone products

What do employers need to know in order to maximize the value of integration?
Employers should ask their health carrier about whether they have ready and timely access to data, and how this data is being integrated with their programs and services. They should also ask about how information flows within the organization and how people work together throughout the organization to deliver services.

At the same time, employers should educate and encourage employees to participate in the disease prevention programs and maximize the services that are available from their health plan.

Mark Hanrahan is vice president of sales and service for Aetna’s north central west region. Reach him at (312) 928-3104 or [email protected].