Saving $82 million with proactive UM and analytics

Building a multidisciplinary team to address the specific needs of members

The client sought Sagility’s expertise to develop a well-defined care management program to lower high care costs across the state. To accomplish this, Sagility paid close attention to staffing ratios assigned to the program’s high-cost beneficiaries. We customized the team to the needs of the rural membership, building in a strong contingent of community health workers and social workers.

Our multidisciplinary team included disease management and complex case management RNs, social workers, and community health workers. This talent mix leveraged our analytics and modeling to accurately identify the most vulnerable and high-cost members of this population. We adjusted our strategy to meet client deliverables on enrollment engagement case management ratios, and nurse-to-member ratios. The result was strong performance across these metrics, with proactive, laser-focused utilization and high engagement in complex case management support.

Reducing cost by ensuring early determination and treatment of high-cost individuals

Our precisely targeted stratification focus and utilization management ensured early determination and treatment of high-cost individuals, before expensive health events. Our actionable data and analysis helped predict potential outcomes and then improve alignment of care team resources, with focus on unique member needs. We shifted some of our focus from Risk 4 to Risk 2, for immediate, early impact to drive down costs and improve alignment of care team resources, with focus on unique member needs. As a result of our care and cost containment strategy, we saved the client $82.5 million over four years, supported by an 18% decrease in cost trend. In addition to these outcomes, we also ensured the most impactable member focus for a more than 60% engagement in complex case management. Our resulting client savings achieved were as a result of our people-process-technology—the analytics and stratification we provided as supported by domain expertise at the right staffing skills and ratios, with more focus on care outcomes.

Improving clinical outcomes

In addition to cost savings, the client was highly focused on improving clinical outcomes, as the program was responsible for measuring performance against 89 different HEDIS measures and an additional 25 measures. From day one, Sagility worked with the client to meet stringent measurements with a chronic care focus and preventive SDOH identification and treatment. Our strategy assessed the transient nature of the member population and the need to keep these individuals at home, supported by food delivery and grants to pay utilities, transportation, physician visit help, and other care basics. As a pioneer in SDOH assessment, we conducted a deep-dive data mining analysis to determine 90% of this population had these conditions. Team members prioritized developing relationships with empathy and understanding, to earn the trust of individuals required to drive meaningful change.

Promote community health behavior

Sagility leveraged our unique combination of clinical expertise, analytics, and community knowledge to get to the heart of poor health behavior. Our community health workers were highly influential in achieving our mission: to keep members at home, in place, and healthy. Together, our team ensured close work with members to remove barriers and coordinate services to improve health outcomes and drive appropriate utilization of health plan benefits and services.

Over the four-year partnership, our rigorous SDOH focus improved medication adherence for coronary artery disease by 222%, with a 22% improvement for diabetes medication. Additionally, our chronic care focus helped support a 31% decrease in inpatient admissions for active cancer patients. Preventive care improvements also included a 223% increase in influenza vaccine administration and annual screening increases of 95%. For physician visits and inpatient or ED visits, our collaborative care coordination delivered a 316% increase in instruction compliance, with a particular focus on CHF patients. Our value-based initiatives in these areas helped individuals get the comprehensive, continuous, quality medical care they needed at home—keeping them in place and focused on maximized health.