Three ways health plans are using real-time clinical data to drive improved member outcomes

As commercial health insurers expand their Medicare Advantage (MA) offerings, the ability to closely control both the cost and quality of the care being provided to this higher-risk member population is critical for plan viability. Many Medicare beneficiaries are dealing with at least one chronic condition, and some have multiple comorbidities. These members are also more likely to suffer from functional and/or cognitive impairment, and as they age, a significant portion have permanent disabilities. In a nutshell, these members are typically amongst an insurer’s most costly and require more hands-on and timely medical management and intervention than other cohorts.  

While insurers tend to have strong ties to acute care settings and established processes that can be used to track MA members when they go into the hospital for surgery or to be treated for acute illness, the majority have only a vague idea of what’s happening after they are discharged. Critically, post-acute care can be responsible for as much as 40% of the total cost of care for MA members. Most payers are reliant on claims data to understand the volume and value of services being utilized in post-acute settings, but by the time this retrospective data comes in, it’s way too late to take action and impact what’s happening to the member. That’s why the most innovative payers are now basing their strategies for managing MA members on real-time clinical data.  

Here are three ways that this strategy is helping payers drive improved outcomes.  

1. Real-time data reduces hospital readmissions  
   Readmissions from post-acute facilities such as SNFs are extremely common for MA members. Many of these readmissions are preventable, but only if the payer’s case managers are actively following the members. When a member falls in a SNF, for example, they may be sent to the ED for assessment and treatment. In many cases, it would be clinically appropriate for the member to return to the SNF without being admitted to the treating hospital, but that’s not what usually happens. By the time payer case managers learn about the ED visit and the subsequent rehospitalization, there’s nothing to do about it, and additional issues, such as discharge to a different SNF, may have occurred in the interim. Having access to real-time data allows these case managers to intervene in real time and redirect members to appropriate care settings, keeping them on the clinical trajectory that is most likely to result in their eventual return home. 
2. Real-time data reduces length of stay 
   Hospital stays are expensive, and payers have long been in the practice of scrutinizing inpatient days and working with hospital case managers during member stays to ensure timely discharges and minimize excess days. Post-acute care can be almost as expensive, and the same principles for management of length of stay must apply to avoid overutilization of these services by MA members. The average SNF, for example, costs between $500 and $700 a day. The only way to prevent unnecessarily long stays is to track the member’s progress during their post-acute stay. Some payers have tried to accomplish this goal by sending staff out to post-acute care facilities to check on members and assess overall quality of care being provided at the facility, but this strategy is unsustainable, as well as unnecessary. A much more effective and scalable approach as Medicare Advantage grows is to tap into real-time clinical data from the post-acute providers and receive alerts when members are approaching established benchmarks for length of stay so that case managers can act.   
3. Real-time data helps grow a network of high-quality PAC providers 
   Reducing readmissions and excessively long SNF stays for individual members is all well and good, but ultimately payers need a strategy that allows them to succeed at the population level to remain viable with Medicare Advantage. They need to be able to assess and compare providers on key metrics and then select a small subset to work with that perform well in these areas. In the past, payers have relied on provider self-reporting, claims data, and even the Medicare Star Ratings to select their preferred post-acute providers. To get a truly accurate understanding of how these providers are performing, however, payers need real-time clinical data aggregated over time and reviewed within the context of appropriate benchmarks.  

Learn more about CarePort’s solutions for payers to track their members across the continuum in real time.