Risk & Business Magazine California Fall 2017 | Page 7

MEDICAL MANAGEMENT MATTERS
right vendors to satisfy the client. events (and the claims that they generate)?
Make no mistake—there are no two vendors
in the self-funded health plan space who do
things exactly the same (if there were, they
would have merged by now!). It’s the plan
advisor’s role to play matchmaker and bring
to the table those vendors who are the right
fit for the group. Furthermore, not only does
the advisor help marry vendors to the client
but the advisor makes sure that those vendors
will integrate together so that the plan has
one cohesive benefit offering that serves its
members well and responsibly. And the third purpose is to help you select
which bolt-on products and services are
actually going to generate a return on
investment (ROI) for your self-funded health
plan. That shiny new toy may look awfully
appealing—the fancy event the vendor
throws and the enormously compelling
guest speaker. Too often I see groups buy
products and hire specialty vendors because
they were enticed by the shimmer, but had
they analyzed their data, they would have
known that the investment was a waste
of time and money! Why buy biometric
screening blood draws (a proposition one
of my clients was recently considering) if
only seven people on your health plan have
skipped their annual physicals while the
other five hundred people already got the
blood draw during their physicals? Do you
really want to invest time and money into
redoing blood work on all those people just
to help only seven?!? Your data should help
you determine which investments are going
to generate meaningful clinical outcomes for
your patients and financial outcomes for your
plan!
There is one other absolutely essential piece
that the best advisors bring to the table—
actionable data. Don’t make the mistake of
thinking that the data you gathered from a
fully-insured-to-self-funded conversion is
all that you need. Every self-funded group
needs ongoing data aggregation and analysis
to ensure that it is optimally managing its
health plan to meet the goals and objectives
that it established when it went self-funded.
In addition to being a critical performance
measurement tool, this data should also
serve at least three other key purposes.
First, it should be a tool that your medical
management vendor utilizes to identify
members who need to be engaged with
medical management services. Data without
action is death! If the clinicians in charge
of helping your members get the right care,
at the right time, in the right place, and for
the right price are not utilizing your group’s
medical and pharmacy data as a member
identification and engagement outreach
tool, then you’ve got the wrong medical
management vendor!
Further, the tool needs to be one that is
actuarially certified for its predictive risk
modeling accuracy. Yes, your data can be
used to predict the future! Additionally,
your medical management team—that
group of nurses and physicians you count
on to help your members—should be
using those predictions to engage patients
and prevent those future health events.
We all know it, deep down inside, that
healthier people file fewer claims. But
there’s significant merit to focusing your
efforts (and investments) on helping those
individuals whom you can see coming down
the pike as future catastrophic claimants!
Why would you not want to help those
individuals avoid those cataclysmic health
expertise they need, what questions to ask
their providers, what treatment options are
scientifically proven to be most helpful for
their particular condition or situation, what a
fair price for their healthcare services would
be, and how to utilize their health insurance
to their optimum benefit. An elite medical
management program will help to identify
the right patients for assistance (both those
sick right now today and those likely to be
sick tomorrow), and engage with them to
ensure that they are getting the right care, at
the right time, in the right place, and for the
right price.
Yes, it’s a lot of work. Yes, you have to do
significant ongoing communication with
your employees. Yes, your people will love
you for giving them a helping hand during
a painful (often literally) period in their life.
Yes, you will see significant cost benefits from
doing superior medical management. But
ultimately, it’s not about the money. That’s
just a happy coincidence of doing the right
thing for the people who keep your business
running day after day. +
I alluded to the role of
medical management in
engaging members of your
health plan, but I want to
be very specific here and
drill down on some critical
elements. Your medical
management component,
and selecting the right
one, is probably the most
critical decision you will
have to make as a health
plan sponsor. Whether
you are fully insured or
self-funded, if you do not
have the right team of
nurses and doctors helping
the members of your
health plan to efficiently
and effectively navigate
both the health delivery
and health plan systems,
then you are doing those
members (and yourself) a
huge disservice.
It is virtually impossible
for patients to know
which providers have the
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