Duals Plan Saves $51M with Risk Stratification and Care Management Advancements
About the Client
- Plan Type: Dual Special Needs Plan (D-SNP)
- Plan Size: 50,000
- Geography: New England
Issue
A Dual Special Needs Plan (D-SNP) located in the northeast faced unsustainable costs, with 68% of its members relying on home health services on an ongoing basis.
The plan serves a highly complex population, including members living with severe and persistent mental illness (SPMI), multiple chronic conditions, functional impairments, and varying social determinants of health, requiring highly individualized care coordination.
The plan’s utilization management (UM) and case management (CM) processes and policies contributed to high costs for services that were not effective, specifically:
- Overutilization and a review process that unintentionally allowed members without high needs to receive services on a long-term basis.
- High authorization volume relative to the number of covered members.
- Increased cost of services without improved outcomes.
The plan needed a rigorous, risk-adjusted strategy to deliver care to the members who needed it most.
Action
To help the plan reduce home health spending while ensuring appropriate care delivery, Sagility consulted on UM and CM strategies, focusing on improving resource allocation and program structure:
- Proprietary Risk Index: Used frailty indicators and behavioral health factors to identify high-risk members who could benefit from early intervention.
- Targeted Management Strategy: Implemented a combined UM and CM approach to build a more effective home health program through early identification and intervention.
- Stratified, Enhanced Case Management: Applied risk stratification to delay or prevent unnecessary services for frail members and developed individualized care plans with bundled services.
- Fraud, Waste, and Abuse (FWA) Analytics: Deployed FWA analytics to detect and address outlier provider behavior.
Impact
Sagility’s data-driven, risk-based strategy delivered measurable impact across clinical, operational and financial areas.
By stratifying the population based on frailty, behavioral health status and activities of daily living (ADL) usage, we optimized the plan’s home health program without compromising care quality. Key results included:
- Identified and eliminated unnecessary home health spending for non-frail members with low behavioral health needs and minimal ADL usage, uncovering $51 million in potential savings.
- Maintained support for frail members through bundled care and improved utilization oversight.
- Lowered total cost of care while continuing to deliver individualized services to high-need members.
This targeted approach preserved critical resources, prioritized the most vulnerable members and strengthened program sustainability.
in potential savings uncovered
