Energizing employees about their health benefits

Surveys show that health benefits selection is confusing and stressful for employees. Getting your employees more involved in open enrollment and other benefits administration activities can pay big dividends in reducing this negative experience, says Jo Hartoyo, CTO at eBenefits Solutions, an affiliate company of the UPMC Insurance Services Division. This division includes UPMC Health Plan, UPMC WorkPartners, LifeSolutions, UPMC for Life, UPMC for You, UPMC for Kids and Community Care Behavioral Health.

Smart Business spoke with Hartoyo about ways to engage employees through their benefits selections.

What are the benefits of increased employee engagement?

According to a recent survey, when employees are actively engaged in choosing their benefit options, they are three times more likely to be satisfied with their jobs than employees who are not actively engaged.

Those who are actively engaged in choosing their benefits are twice as likely to value those benefits their employer is offering.

The key takeaway is that a more engaged employee is going to make better-informed benefit choices. This helps both the employee and the employer. The employee can potentially save thousands of dollars by choosing the right plan and the employer is more likely to save on overall health care costs.

How can employers encourage more engagement?

  1. Offer integrated tools. It’s best to integrate decision-making tools, cost calculators and other helpful information directly into the benefits enrollment process. These tools enhance the benefits enrollment experience and provide a more interactive, engaging experience. This makes it easier for employees to evaluate options and to make the right decisions. This enhanced level of self-service has the beneficial side effect of freeing up your HR business partners so they can tend to higher-level strategic programs aimed at achieving the organization’s goals.
  2. Provide user-friendly, web-based technology. Better-designed technology with simpler, more intuitive interfaces is vital for increasing employee engagement. Employees are consumers and, as such, expect retail-like websites that are easy to use. It’s also vital to allow employees the ability to enroll in and manage all of their benefits seamlessly through a secure single-sign-on technology platform.
    In addition, single-page applications allow employees to access their benefits, claims information and human resource updates all on the same screen, as opposed to skipping around from screen to screen where each page has a different look and feel. The one-screen approach makes navigation far simpler, more intuitive and more responsive for a better overall user experience.
  3. Communicate with a multi-channeled approach. A workplace survey found that when employees received benefits communications through their preferred channels — via print, email, onsite meetings or a combination — 70 percent were very confident in their selections. When employees didn’t receive benefits communications through their preferred channels, less than 40 percent were very confident in their selections. Overall, the study showed that when employees both receive communications and enroll through their preferred channels, they are more likely to make better enrollment decisions. They are more informed about health benefit details such as deductibles, out of pocket maximums, and employer contributions.

At the end of the day, in order to energize and engage your employees with their benefits, you want to make things easy for them.

A basic example of this is to allow employees to enroll online. This means employees can sign up 24/7 from their home or office and can check their selections and benefits any time. It’s also much easier for employees to compare plan options and benefit details when everything is online.

These simple strategies will yield a huge payoff in terms of getting employees more engaged in the process and happier with their benefit selections. This translates to more satisfied employees and higher employee retention.

Insights Health Care is brought to you by UPMC Health Plan

How to integrate leave of absence and employee assistance programs

A 2013 study by the Integrated Benefits Institute (IBI) reported that the prevalence of depression among workers is close to 20 percent and that more than 60 percent of these depressed employees go untreated. At the same time, 97 percent of employees who file a leave claim for depression also report other comorbid conditions.

The impact of depression and other conditions may be amplified when employees are on leave caring for family members who need them. At a minimum, there are emotional, financial and lifestyle implications for these employees.

For employers, the IBI study estimated the yearly cost in lost work time and medical treatments at $62,000 per 100 employees. In an internal analysis of its parent company, WorkPartners discovered that employees who took a leave of absence were 5 percent more likely to suffer depression than they were before taking the leave.

Smart Business spoke with Jim Kinville, senior director of LifeSolutions, and Linda Croushore, senior director of Disability Services at UPMC, about how employers can help employees who are fighting depression or other conditions while on leave.

How can employers ensure their employees on leave have the resources they need?

To combat these challenges and their associated costs, you’ll want to consider programs that can engage employees on leaves of absence with an employee assistance program (EAP) to help employees manage the range of life challenges they may be facing.

A pilot program included employees who called in to request a leave to care for a spouse, child and/or parent.

The leave intake specialists processed the leaves as normal and then, near the end of the interaction, transferred the employee to a live phone connection with the EAP provider. Next, the EAP care manager engaged the employee in a conversation, giving the employee information on services that may assist the employee based on the details of the individual situation. Each employee’s original EAP care manager then made a follow-up call 30 days later to review the employee’s needs and provide additional support if appropriate.

What types of services would this integrated approach include?

By speaking with the EAP care manager, employees are able to determine services that will best assist them throughout their leave. The types of services used by those who accept assistance will vary, but with the diverse concerns and issues these employees experience as they go through the leave process, the services most utilized tend to be referrals to the Institute on Aging, general counseling, child care, legal services and financial consultations.

Most individuals using leave need to manage multiple issues. EAP care managers report they helped to address nine or more different areas of need related to health, emotional issues, work-life balance, financial, legal and more. In fact, it is rare that someone only has one specific area of need. Care managers have assisted with linkages to other programs, such as wellness coaching and complex case management.

What are the effects of EAP programs on leave duration?

While the results of programs that consider a number of variables (type of leave, leave circumstances, etc.) are still being studied to fully determine the effect of EAP programs on leave duration, some key results from the pilot program included:

  • All employees who were transferred to the EAP accepted the initial services for a 100 percent engagement rate. An informational flier was sent to all callers who agreed to receive it.
  • Care managers reported there were no complaints about the offer of free services through the EAP.
  • Of the employees who were transferred to the EAP, 12 percent accepted services beyond the initial transfer.
  • Employees who used the extra support experienced leave durations that were, on average, four days shorter than those who did not use the support.

Insights Health Care is brought to you by UPMC Health Plan

Do you know the value of positive psychology?

The field of positive psychology has many resources to help us increase positivity in our daily lives.

“This field emerged because leading psychologists believed their discipline could offer help beyond understanding and treating psychological disorders,” says Dennis Daley, Ph.D., senior clinical director of Substance Use Services at UPMC Health Plan. “They began to examine how we can live happier, more fulfilling lives and achieve better health and a longer life.”

Smart Business spoke with Daley about how positivity can lead to a better life.

Can psychology foster positive emotions?

Most people want to feel good. They strive for positive emotions. Positive psychology analyzes these emotions: what they are, how they improve well-being and how to make them a bigger part of your life. They include compassion, happiness, love, gratitude and satisfaction. They are often based in relationships, achievements and a sense of purpose or meaning. Of course, none of this works if we simply ignore problems.

How does positive psychology help you cope with negative events and emotions?

Negativity surrounds us. Most news focuses on problems: bad events, bad behaviors of individuals. Sometimes painful or traumatic events happen in our lives: the death of a loved one, a failed relationship, job loss or another significant loss. We cannot avoid negative emotions or events — nor should we. But emotions can be used in positive ways to serve important functions:

Anger is negative when it:
— Leads to giving up too easily on a problem or task.
— Is expressed verbally or physically in an aggressive or violent manner.
— Is stifled and shows up in physical symptoms or passive-aggressive behaviors that harm a relationship.

But is positive when it:
— Motivates us to work hard to achieve a goal, complete a project or task, or face a difficult experience or person.

Anxiety/fear is negative when it:
— Becomes persistent and overwhelms us.
— Leads to physical and emotional distress or avoidant behavior.
— Is symptomatic of an anxiety disorder.

But is positive when it:
— Helps us stay vigilant to avoid or minimize threats.
— Motivates us to better prepare for a job interview, an important meeting or a presentation at work or school.

Grief is negative when it:
— Is too intense over a long time.
— Interferes with our ability to function or form new relationships through the grief process.

But is positive when it:
— Is a way of expressing our suffering as well as our love for a lost loved one.
— Leads others to show their love and support and help us.
— Deepens our commitment to other loved ones, or has positive effects on spiritual or religious beliefs or practices.

Guilt is negative when it:
— Leads to obsessive thoughts that make it difficult to focus on daily living.
— Makes us reluctant to enjoy life and more willing to punish ourselves.

But is positive when it:
— Influences us to correct problems in relationships or change our behavior that others find hurtful.

Positivity helps us keep our lives balanced so that negative emotions don’t drag us down too far. When we work at positivity, it becomes easier to know when that balance is upset and we need help dealing with our emotions. We often judge ourselves harshly, beating ourselves up over our faults, flaws and shortcomings. That makes us feel isolated, unhappy and even more stressed; it may even make us try to feel better about ourselves by denigrating other people.

Rather than harsh self-criticism, a healthier response is to treat yourself with compassion and understanding. According to psychologist Kristin Neff, this self-compassion has three main components: mindfulness, a feeling of common humanity and self-kindness. She suggests that you write a letter to yourself expressing compassion for an aspect of yourself that you don’t like. Research suggests that people who respond with compassion to their flaws and setbacks experience greater physical and mental health.

Insights Health Care is brought to you by UPMC Health Plan

Payer-provider integration is key to nationwide health care reform

Individuals and business have long sought changes to our health care system that would improve its quality and reduce the cost of care coverage.

“However, systematic solutions have been hard to find; health care in the U.S. is more costly than other developed nations without delivering better outcomes. We seek evidence of payment and delivery structures that deliver better care at lower costs,” says Dr. William H. Shrank, chief medical officer at UPMC Health Plan.

Studies have shown that greater provider consolidation leads to increased costs. Yet, consolidation, when coupled with integration of a payer and provider, seems to deliver different results.

Smart Business spoke with Shrank about an integrated delivery and finance system (IDFS) that was pioneered in Pittsburgh, which could serve as a national model for better care at lower costs.

How did the IDFS model emerge in Western Pennsylvania?

UPMC took the first step in establishing an IDFS when it launched its health plan in 1996. At the time, Pittsburgh was one of the nation’s least competitive health care environments with a dominant payer negotiating with a dominant provider.

An IDFS could align incentives, support value-driven health care and eliminate data silos. Furthermore, such a system would focus the payer and providers on:

  • Reducing low-value treatment and over diagnosis.
  • Shifting services to the most appropriate, cost-efficient settings.
  • Preventing and managing chronic diseases.
  • Implementing more efficient, coordinated models of care.
  • Integrating real-time data to support improved clinical decision-making.
  • Optimizing clinical and financial performance.

How did this payer-provider strategy change the health care landscape in the market?

More than 20 years later, this aligned payer-provider strategy has helped to drastically change the health care landscape. Patients and providers now have easy access to the information they need for efficient and effective care coordination. Providers are able to make measurable changes in their patients’ health and quality of life.

There are now two IDFSs and multiple national insurers competing in Western Pennsylvania. The region’s insurance prices are among the lowest in the nation. Fully insured commercial premiums for employer groups and premiums for individuals covered through commercial insurance products are less expensive in Pittsburgh than in almost every other major market. At the same time, the region experienced improvements in health care quality and considerable investments and innovation in medical science and health care delivery.

What is the potential value of this model to other health care providers?

The success of Pittsburgh suggests that when providers and payers work together to improve quality and reduce costs, good things can happen for patients, organizations and the communities they serve.

As people search for solutions to transform the health care system to produce greater value, the integration of insurance and health care delivery ought to be considered as a central strategy.

How do you think policymakers can support provider and payer collaboration?

Integrated payer and provider systems have the potential to not only manage costs, but also to work together to address critical public health issues, such as the opioid epidemic, to drive reductions in inappropriate prescription drug use, and improve member safety through integrated data that supports clinical decision-making.

As policymakers consider options to improve the health of our nation and reduce health care costs, marketplace structure should be central. They should look for ways to support new models of provider and payer collaborations that enable providers to develop key competencies, such as consumer engagement and member management processes, risk analysis and reimbursement modeling. These competencies are essential for improving clinical quality, patient satisfaction and costs within integrated systems.

Insights Health Care is brought to you by UPMC Health Plan

Diet and nutrition have a hand in chronic health conditions

When you think about treating chronic health conditions, you may focus on therapies to address those diseases. But there are other components to consider when it comes to curing, controlling and preventing illnesses: diet and nutrition.

“What and how much you eat and drink can ease or exacerbate your chronic health conditions. If you don’t have a chronic condition, changing your diet may keep you from developing one,” says Karen DePasquale, LSW, ACSW, associate vice president of Clinical Affairs and Business Operations at UPMC Health Plan.

Smart Business spoke with DePasquale about how diet can cure, control and prevent chronic health conditions, and why employers should use health coaches to encourage this in their employees.

What are some chronic diseases where your diet and nutrition can play a large role?

  • Obesity: Eating more calories than you burn can lead you to become overweight or obese. This can cause serious health issues. Taking steps to address your diet and stop (or reverse) weight gain can positively affect your health.
  • Diabetes: There are many risk factors for type 2 diabetes, including age, race and genetics. But 90 percent of individuals with the disease are overweight or obese. Studies show that lifestyle changes — including weight loss and increasing your level of activity — can prevent or delay the disease’s development, according to the Obesity Society.
  • Cardiovascular diseases: Eating an unbalanced diet high in saturated and trans fats and lacking in fruits, vegetables and polyunsaturated fat can increase your risk of heart disease and strokes. Consuming too much salt can cause high blood pressure, another major cause of cardiovascular diseases.
  • Cancer: A healthy diet with adequate amounts of fruits and vegetables can help reduce your risk for oral, esophageal, stomach and colorectal cancers. Such a diet should also help you maintain a healthy weight, and that can reduce your risk for breast, kidney and endometrium cancers, according to a report by the World Health Organization.
  • Osteoporosis and bone fractures: As you age, your bones can become more susceptible to fractures. To reduce your risk, you should consume adequate amounts of calcium and vitamin D, and make sure you are getting enough sun exposure and performing muscle- and bone-strengthening exercises.
  • Dental disease: The acids and sugar in many foods and beverages can damage your teeth and gums. Limiting these foods can provide protection, as can getting regular fluoride treatments.

If you are at risk for any of these conditions or are dealing with one or more of them, remember that it’s not too late to make a change. Simple changes to your diet, in conjunction with your physician’s recommended treatment plan, can go a long way toward managing your chronic health conditions.

How can health coaching positively impact your workplace?

Having a healthy diet can cure, control and prevent chronic health conditions. Even so, it isn’t always easy for people to change what they eat and drink — especially in today’s always-on-the-go workplace. Employees are busy and can be tempted by unhealthy choices like fast food and vending machines. Sustained motivation through a health coaching program can make a significant difference in helping employees accomplish lifestyle change goals.

Health coaches are supportive, knowledgeable professionals and include licensed nurses, counselors, registered dietitians, social workers and exercise physiologists. They provide one-on-one telephone or online support, as often as needed, to help employees change their lifestyle or manage a chronic health condition that has changed their life. Health coaches help employees identify and tackle challenges to get them on the road to better health by setting goals and finding the best ways for members to reach them.

Offering a health coaching program lets your employees know you care about them, which can have a positive impact on morale and productivity. This type of program can also help you attract new talent and retain extraordinary employees.

Insights Health Care is brought to you by UPMC Health Plan

The Bermuda Triangle of HR law: What employers need to know

Some employee absence events may trigger not just one law, but the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA) and state workers’ compensation laws. Violations of these laws may cause penalties to employers and, in some cases, even to managers.

Smart Business spoke with Linda Croushore, senior director of Disability Services, and Jeffrey Swaney, vice president of Workers’ Compensation, at WorkPartners, about the overlap among ADA, FMLA and workers’ compensation.

Who can trigger ADA, FMLA or workers’ compensation? In what instances will more than one law apply?

It is generally the employee’s responsibility to inform the employer about the need for an accommodation, related to a medical condition, to enable the employee to fulfill the essential duties of the job. However, failure to clearly request an accommodation or provide this information hasn’t always prevented lawsuits. In some cases, courts held that erratic employee behavior was a sufficient notice of need for an accommodation. In addition, a doctor, family member or other qualified person can make requests ‘on behalf of’ the employee. Employees cannot simply stop reporting for work; some notice is required by the FMLA.

With workers’ compensation, every state has its own laws and regulations, but the claim for a work-related injury should always be reported within 24 hours of the injury. This gives the workers’ compensation program time to assess the claim’s validity. More importantly, care can be directed early in the process as allowed by state statutes.

The ADA, FMLA, and workers’ compensation regulations overlap in several areas; employers must determine which one(s) apply to an employee’s leave request. This overlap can raise questions regarding employer coverage, employee eligibility, length of leave and medical documentation.

How should employers handle leave when there’s overlap among the laws?

Employers operating in this overlap zone need to maintain communication and require appropriate medical documentation. When these best practices falter, cases start to run off the rails because most leaves contain too many nuances for employees to comply without ongoing guidance.

Sending a startup letter or medical certification form isn’t enough. Employers that require fitness-for-duty certification should have a uniform FMLA policy in the handbook and other written communication to employees. The employer must give the employee a list of the essential job functions for use in the certification. The certification states the employee is able to resume work following an FMLA leave. It can address the employee’s ability to perform the essential functions of the job and is signed by the employee’s health care provider. Employers shouldn’t refuse to let an individual with a restriction return to work simply because the worker isn’t fully recovered from the injury. This will likely result in an ADA violation.

The interactive process begins when an employer learns of the need for an accommodation. Even when an employer believes no accommodation is possible, the ADA requires an ‘interactive process’ to discuss the situation with the disabled worker; health care providers are often included. Rather than moving straight to the undue hardship argument, employers should thoughtfully evaluate the accommodation request. Does the proposed accommodation provide for the safety of employees and customers? Does it remove any essential functions? Will it negatively impact work or product quality? The process may require multiple cycles to explore possible job modifications, more leave time or other alternatives.

Employers shouldn’t place the burden on the employee to identify open positions that meet the accommodation request. Yet, it’s imperative that employers document all efforts of an employee — or the lack of effort — to engage in this interactive process.

When employers consider all elements while managing an employee leave or claim, the overlapping processes of ADA, FMLA, and workers’ compensation run more smoothly. Because the ADA interacts significantly with the other two, the ADA interactive process is key to helping employers avoid being sucked into the Bermuda Triangle of HR law.

Insights Health Care is brought to you by UPMC Health Plan

How to keep sickness away from your vacation

With the school year over and warm weather here, vacation season is coming. Whether you’re seeing new places or revisiting a familiar favorite, disconnecting from work and spending time with friends and family allows most people to come back to work feeling fresher and more productive.

And it’s important to take that time. According to a 2016 Harvard Business Review article, a U.S. Travel Association study found that 95 percent of people surveyed claimed using their paid time off was very important. And yet more than half of Americans (55 percent) left vacation days unused, which equates to 658 million unused vacation days.

But even if you take your vacation, what happens if you spend the time sick?

Smart Business spoke with Melinda L. Schriver, senior director of Telehealth Strategic Solutions at UPMC Health Plan, about staying healthy on your vacation.

How can people avoid getting sick on vacation time?

No one wants to get sick during vacation, but it happens. Here’s what you need to know to prevent or minimize the impact of a medical issue on your precious time off:

  • If you take medication, make sure to bring enough to last the entire trip. Pack medications in your purse or carry-on bag; do not put them in checked luggage.
  • If any of your medications are controlled or injectable substances, carry a letter from the prescribing physician on official letterhead.
  • If you wear glasses, pack a spare pair. You may also want to take a copy of the lens prescription just in case.
  • Pack a travel health kit that includes pain relief, such as ibuprofen or naproxen, Band-Aids, antiseptic cream, and drugs for an upset stomach and motion sickness. For international travel, research what you should and should not eat and drink. You may need to stick to bottled water and avoid foods that haven’t been cooked or peeled.
  • Don’t forget sunscreen (with an SPF of at least 30) and insect repellant (if you’ll need them).
  • To prevent catching a cold while airborne, bring your own disinfecting wipes and wipe off the tray and armrests. Wash your hands often and stay hydrated. Get up and move around every hour or two.
  • If you’re driving to your destination, make sure you’re well rested. According to the National Highway Traffic Safety Commission, driving while drowsy is a contributing factor in 72,000 accidents annually. Switch drivers, if possible, every few hours.

How does the stress of getting ready impact your immune system?

If you worked late hours tying up loose ends before a trip, that stress can shift your immune system into high gear. Once your stress levels drop, your immune system may also downshift and leave you exposed to pathogens. Try to keep everything in perspective. A recent University of Chicago study found that people experienced similar levels of enjoyment on their vacation regardless of whether they completed all their work first.

What if you do get sick?

Food poisoning, sunburn and sinus infections can happen despite the most careful planning. If someone you’re traveling with needs treatment for a nonemergency medical condition, telemedicine providers can address some of the most common issues through a virtual visit via smartphone, tablet or computer. Providers can even prescribe medicine when necessary. Plus, telemedicine services mean you won’t waste time trying to find an urgent care clinic or an emergency room when you’re in unfamiliar surroundings.

Many insurance companies cover telemedicine. The cost is often less than an urgent care or emergency room visit. Be sure to find out the details of your plan’s coverage before you go. For example, UPMC Health Plan covers its members when traveling through nationwide virtual urgent care visits, a large national urgent care network, a robust extended network, emergency care coverage and a growing telemedicine program.

Insights Health Care is brought to you by UPMC Health Plan

Integrating utilization and case management for optimal results

Medical management programs are typically comprised of multiple services designed to help control health care costs and ensure optimal health outcomes for employees.

“While these sorts of programs can be used individually, they are really intended to work together to provide an integrated approach to managing an employee’s total health,” says Amy Cleveland, HealthLink director of Medical Management.

Employers who don’t have a complete understanding of medical management programs may be missing out on the many advantages of an integrated approach by “carving out” or removing certain programs and services.

“When employers leave even one medical management service out of their plan, the program does not work as intended, which can put the good health of their employees and their spending at risk,” Cleveland says.

Smart Business spoke with Cleveland about integrating medical management.

What is utilization management?

Utilization management (UM) consists of multiple programs designed to encourage appropriate use and performance of medical services in accordance with evidence-based guidelines. Typically, UM consists of pre-certification reviews for hospital admissions, certain medications and high-tech imaging services, such as MRIs and CAT scans, as well as continued stay review, discharge planning, proactive screening for case management (CM) and more. These services can ensure employees get the right level of care at the right time, and that their treatment meets the health plan’s standards.

How should CM work?

CM nurses are responsible for developing individualized care plans for employees identified as at-risk for high utilization and/or high dollar claims. These plans assist employees with complex care needs, improve their experience, promote safe and timely transitions in care and encourage efficient delivery of services and cost savings. The CM team’s goal is to assist in an employee’s recovery to help them navigate the health care system and offer added support.

What are the advantages of integrating these programs?

When UM and CM are fully integrated, it allows for a comprehensive approach to managing employees’ health. Employees can be proactively screened during the UM process and clinical reviews to see if they are a candidate for CM. These high-risk employees can then be engaged much sooner, which leads to better health outcomes. This sort of integration gives CM teams the ability to engage employees in real time, rather than using past claims data to determine eligibility. It also allows for regular communication and coordination between the UM and CM nurses to ensure care plans are as customized and patient-focused as possible. This elevates a medical management program to real-time engagement in the quality of care.

What are the downfalls of carving one of these services out?

When one program is carved out, the other cannot work as effectively. If an employer chooses CM services, but not UM, employees can no longer be pre-screened and engaged in real time. In this instance, utilization and spending reports would be the only tool used to attempt to identify high-risk employees. Often, these employees don’t need services anymore. The opportunity to help employees and contain costs is missed.

How can employers decide if integrated medical management is right for them?

For many employers, cost containment is a driving factor for considering a medical management program. Unfortunately, most employers don’t fully understand the major advantages to employee health and cost containment opportunities that a complete, fully-integrated program offers.

Employers who are considering a medical management program should talk to their broker, third party administrator, network partner or carrier to be fully educated about the impact a medical management program can have on their health plan.

Insights Health Care is brought to you by HealthLink

How clinical intervention can improve the health of those at highest risk

The high-risk top 5 percent typically drive more than 50 percent of overall health care spending when absenteeism, disability and workers’ compensation are included.

Predictive analytics that weigh workers’ compensation, disability, incidental absence, and medical and pharmaceutical claims can be combined to create a risk index that provides early identification of individuals who will soon be both high-risk and high-cost. Clinical intervention can then be offered to those who need it most.

Smart Business spoke with Justin Schaneman, MS, vice president of Data Analytics, and Rene Sims, MSN, vice president of Clinical Services at HCMS Group, a WorkPartners affiliate, about how to create a holistic clinical prevention model, the second of two articles on leveraging integrated data and applying it to clinical interventions.

How does a holistic clinical prevention program work?

Individuals identified through predictive analytics should be invited to enroll in a clinical prevention program, based on the employer’s cultural preferences. This model uses a holistic approach beyond conventional disease management, which is typically triggered by specific conditions such as diabetes or cancer. The data for high-risk individuals consistently shows that costs associated with multiple conditions often produce a cascading effect. Addressing all the conditions, including work, family and social issues helps individuals navigate the health care system and make better decisions about their treatment, leading to fewer relapses and a more sustainable recovery.

Individuals can be invited through a series of outreach calls and letters. Enrollment rates are typically high because these individuals often feel desperately lost in the fragmented health care system and welcome the additional resources.

In this model, a nurse serves as the primary point of contact and continually evaluates the individual’s needs while adjusting the action plan to address those needs. Medications are reviewed by a pharmacist to assist with issues, such as a need for lower-cost options, negative side-effects and the risk of interactions between multiple medications. A medical research librarian provides information to help members take control of their health and make health care decisions that lead to improved outcomes.

What kinds of results can be expected?

In our experience, within a year of enrolling, about half of participants see significant improvement in health, risk and utilization metrics. It may take longer for participants with more complex situations to ‘graduate.’ Measures of success include engagement with a primary care provider; a decrease in the number of prescription drugs, specialists and lost work days; increased productivity at work; and improved quality of life.

HCMS conducted a pre/post enrollment study of 3,864 enrollees who went into a clinical prevention service from 10 companies in 2016. The companies ranged from 500 to 21,000 workers across multiple industry sectors. The most drastic decreases occurred in the number of medical tests, which correlated to a significant decrease in visits to multiple medical providers. The second biggest impact was a reduction in the number of medications. In some cases, the number of diagnoses decreased by the time an individual graduated from the program.

It’s common for people in high-risk groups to experience high-cost events for a matter of months and then begin to recover. Typically, there is a rapid increase in the costs of absence, disability and health care, followed by a rapid decline. However, for individuals enrolled in a clinical prevention model, the decline starts significantly sooner and falls significantly more. This results in tangible cost savings during the first year after intervention.

By providing high-touch clinical support and actionable information across all dimensions, this model empowers individuals to take charge of their health and improve the quality of their life.

As big data opportunities expand in the workforce health arena, advanced analytic and predictive modeling is becoming even more relevant and can improve outcomes for both the employee and employer. The key is to partner this predictive power with a clinical service that can leverage that intelligence effectively, targeting individuals who will benefit from the service.

Insights Health Care is brought to you by UPMC Health Plan

How to leverage data to predict the 5 percent who drive the most health cost

Many employers receive an annual report from health plans listing high-cost claims. Most find themselves looking in the rearview mirror wondering what they could have done to prevent such costly episodes or at least reduce their impact.

This impact goes far beyond the rising costs of health care. A HCMS Group study found the top 5 percent of cases drove over 50 percent of overall spending when absenteeism, disability and workers’ compensation were included. Fortunately, it’s possible to leverage integrated data to predict which individuals are headed toward this top 5 percent, allowing employers to offer uniquely targeted clinical prevention.

But the stakes are high and rising. The HCMS Group’s Research Reference Database, covering 3.8 million members, revealed that the number of cases costing at least $100,000 each year has climbed 16 percent since 2015 and now averages five per 1,000 members. Cases costing $500,000 or more per year have increased 22 percent over the same time period.

High-cost cases happen to high-risk individuals — those with multiple conditions who often deal with family and work issues. They typically consume health care, lost time and disability benefits at a much higher rate. This comes at a price to their health and to their employer’s bottom line. Many individuals stay in the top 5 percent cost range year after year with multiple family members in the top 5 percent at the same time.

Smart Business spoke with Justin Schaneman, MS, vice president of Data Analytics, and Rene Sims, MSN, vice president of Clinical Services at HCMS Group, a WorkPartners affiliate, about how data can predict your top 5 percent, which is the first of two articles on leveraging integrated data and applying it to clinical interventions.

How is data being used to better predict this risk?

Many employers have gained access to data warehouses, hoping to generate actionable insights from mining big data. The value, however, can be limited when only medical and pharmaceutical expenses are included.

Integrating a broader array of data produces more actionable findings. Expanded databases incorporate disability and absence data, which reflect the policies that drive people’s behavior and consumption of benefits. They bring into focus the full cost of burden of disease, illnesses and injuries, allowing employers to better harness the predictive power of their data. Sophisticated employers also include the results of employee performance evaluations, compensation levels, safety violations, training course completions and other person-centric data types.

Once the right data is being collected, how can it be applied to the health plan?

The next step is to fully leverage the value of that broader set of data inputs. An integrated risk index that takes into account compensation and lost time data will dramatically increase the predictive power of the index. This can measure risk related to human capital health and job performance, not just disease. It also provides a leading indicator to flag emerging risk cases early in their trajectory, so interventions can shorten or prevent the period of time when they are both high-risk and high-cost.

Leveraging integrated data on workers’ compensation, disability and incidental absence — in addition to medical and pharmaceutical claims — allows predictive, individual risk indices that enable timely intervention for the high-risk top 5 percent.

This kind of risk index can provide early identification of individuals who will soon be both high-risk and high-cost. Clinical intervention can then be offered to those who need it most.

As big data opportunities continue to expand in the workforce health arena, advanced analytic and predictive modeling approaches are becoming more relevant and can improve outcomes for both the employee and employer. The key is to partner this predictive power with a clinical service that can leverage that intelligence effectively, targeting individuals who will benefit from the service. The next article will discuss how to set up that clinical intervention.

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