How a D-SNP Cut $70M in PCA Spend While Improving Member Outcomes
About the Client
- Plan Type: Dual Special Needs Plan (D-SNP)
- Plan Size: 50,000 members
- Geography: New England
Issue
A northeast Dual Special Needs Plan (D-SNP) faced unsustainable spending on personal care attendant (PCA) services—outpacing their peers. The plan serves a complex population, including members with severe mental illness, chronic conditions, functional impairments, and social barriers. Members rely on individual assistance with daily activities, making PCAs critical to maintaining independence and quality of life. However, the absence of effective oversight led to overutilization and increased costs.
Two factors drove overspend:
- Unclear Medical Necessity Criteria: The plan’s utilization management framework aligned with applicable regulations but did not define what qualified as necessary PCA care.
- No Risk Stratification: Without effective tools to identify high-need members, the plan broadly approved services without pinpointing true clinical need.
To curb costs, the plan implemented a targeted, clinically guided approach to PCA utilization.
Action
Sagility partnered with the plan to develop a comprehensive utilization management (UM) strategy grounded in clinical evidence and analytics. Key interventions included:
- Population-based Insight and Risk Stratification: Employed Sagility’s proprietary risk index to stratify members by frailty, physical versus behavioral health, and medical risk.
- Adoption of UM 360 Management: Implemented Sagility’s multifaceted approach, UM 360, that integrated proprietary frailty criteria for medical necessity, fraud, waste, and abuse (FWA) analytics, enhanced clinical review, and targeted outreach through Sagillity’s aging in place program, Sagility Smart Step™.
- Tailored, Multi-modal Strategy: Deployed targeted interventions for specific member cohorts, incorporating enhanced screening for frailty and activities of daily living (ADLs).
Together, these interventions established a clinically aligned framework that delivered measurable improvements in cost and care.
Impact
Sagility’s strategic redesign of PCA service delivery created meaningful, measurable impact:
- $70 Million in Potential Savings: Identified through improved screening and lowering overutilization of PCA services across Medicare and Medicaid populations.
- Better Resource Allocation: Focused PCA services on members with high physical dependency, reducing overuse among lower-risk cohorts.
- Enhanced Member Experience: Sagility Smart Step delivered proactive, personalized support that improved quality of life and helped high-risk members remain safely and independently at home.
By aligning PCA services with true clinical need, the plan achieved measurable impact while preserving dignity and care quality for high-need members.
of potential savings identified
