Small population, large expense: Managing the high-cost 2%

Two percent of employees. Almost 50% of an employer’s medical spend.

Those are the facts and figures that comprise the story of the employees and their families who generate the highest amount of medical claims for employers today.1 The two groups that fall into that category are those with chronic conditions and those who’ve faced a catastrophic situation. These populations present complex health care needs that call for a holistic approach to managing costs, with an eye on strong outcomes and experiences for the employee.

“When all the pieces are working together in this holistic approach, it’s like a symphony orchestra,” says Dr. Gerald Hautman, Chief Medical Officer, UnitedHealthcare National Accounts. “If you take out one piece, it just doesn’t sound right. That’s why it’s so important to assemble the right team around the employee, and ensure the team is working together for a common purpose, as defined by the employee.”

3 Key Takeaways

  1. Almost half of an employer’s medical spend is related to employees dealing with chronic or catastrophic conditions.
  2. Catastrophic cases continue to rise in cost and complexity, and employers are searching for ways to predict and manage these cases among their employee populations.
  3. Efficient and effective care is a combination of technology and 1:1 coaching designed to improve outcomes and lower costs.

Diving deeper into chronic conditions

The statistics behind chronic diseases bring the issue into focus:

  • 1 in 4 U.S. adults has 2 or more chronic conditions.2
  • 1 in 3 adults could have diabetes by 2050.3
  • 1 in 5 Americans will develop heart failure.4
  • 20.4 million adults have asthma.5
  • Every 40 seconds, someone has a heart attack.6
  • By 2020, $49 billion in costs will be attributed to chronic obstructive pulmonary disease, or COPD.7

“We see a lot of people who I’d call ‘stable chronic’ being treated inefficiently,” Hautman says. “These people are regularly using the health care system, and doing alright, but their treatment may not be as efficient as it could be. And that means they may not be as healthy as they could be, which not only may translate into lower productivity, but also may put them at risk for bigger health problems down the road.”

So what does efficient and effective care look like? It starts with a combination of technology and 1:1 coaching designed to improve outcomes, increase engagement and, ultimately, lower costs for the employer. Predictive modeling and proactive outreach – grounded in data analysis from health assessments, pharmacy and medical claims, lab data and biometrics – are 2 key outputs of the data-led approach.

Continuous touch-points and integrated analytics give those delivering the care the appropriate line of sight into the right steps to take for the employee.

That’s where the interdisciplinary team comes in. The team, which includes an RN coach, creates multiple engagement opportunities via phone and digital mediums, providing the framework for a whole-person care strategy–an effective framework yielding a $2.68 per-member-per-month reduction in medical costs, resulting in a 3:1 ROI.8

Consider the following example of an employee dealing with heart conditions and getting support through the UnitedHealthcare Heart Failure disease management program with biometric monitoring:

 

This outlines a sample journey for an employee dealing with various heart conditions. It details the interactions she has with her nurse and physician as part of the support provided through the UnitedHealthcare Heart Failure disease management program.

“Good communication with patients and families is so critical,” says Dr. Brenda Bruns, Chief Medical Officer, Enterprise Health Care Value, UnitedHealthcare. “Because so much of chronic disease management depends on making lifestyle and behavior changes, those involved in patient care have to understand what motivates the employee and help provide the tools they need to be as successful as possible.”

The cost of catastrophic care

Effective chronic disease management may help prevent some employees and their family members from moving into the “catastrophic” category. Of course, not all catastrophic situations can be predicted or prevented. People could still be in auto accidents, and otherwise perfectly healthy individuals could still sometimes get cancer or other life-changing diseases.

Catastrophic cases continue to rise in cost and complexity and employers are searching for ways to predict and manage these cases among their employee populations.

Compared to non-catastrophic cases, or those under $100,000, UnitedHealthcare has seen:

  • More money spent on out-of-network care.    
    • 7% of outpatient spend is out of network and 5% of inpatient spend is out of network.9
  •  Less spent on care delivered by UnitedHealth Premium® program providers (Tier 1).
    • 24% of the costs for outpatient care occurred at Premium program facilities; 39% of inpatient spend.10
  • More costs associated with outpatient care and pharmacy – with specialty medications accounting for 6% of total cost for catastrophic cases.11

This data has led UnitedHealthcare to develop a 3-pronged approach for Catastrophic Care Management:

Data and insights: UnitedHealthcare identifies catastrophic conditions early to build a plan for the employee focused on:

  •  Right medication.
  •  Right lifestyle.
  •  Right care.
  •  Right provider.

“People need to hear from a physician or caregiver they trust,” Hautman says. “That’s why it’s so important to connect patients to the right providers and to give those providers access to the tools and data they need to make the best treatment recommendations. Employers and insurers should be doing everything they can to use Centers of Excellence and UnitedHealth Premium providers to guide care.”

Employee/family support: Catastrophic situations are emotional, making the rational elements of care management difficult for employees and their families. Here, an integrated, collaborative clinical team seamlessly supports the employee in areas such as:

  •  Legal assistance.
  •  Care placement.
  •  Care monitoring.
  •  Rehabilitation.
  •  Transportation.

Claims management and reporting: Behind-the-scenes work to help to manage costs includes

  •  Analyzing cost-trend analysis from early intervention
  •  Providing real-time reporting to clients to allow for stop loss
  •  Reviewing trends and catastrophic cases, possibly identifying the need for larger initiatives that should be reviewed or implemented.

For more information related to managing populations dealing with chronic or catastrophic conditions, reach out to your broker, consultant or UnitedHealthcare representative.

Member story: Breast cancer journey

Members stricken with cancer need holistic advocacy that usually starts with friends and family and extends to a team that includes specialized physicians, nurses and all the other caregivers that members connect with along the way. Here’s one member’s story and the support she received.

Care strategies for “healthy” employees

Working to keep employees healthy includes a care-management plan that includes wellness programs. Employers offering a range of qualifying fitness and activity options and celebrating employee successes can go a long way in building a culture of wellness that can have multiple benefits to an organization.

Footnotes

  1. 2019 UnitedHealthcare National Accounts book of business data, medical only.
  2. Centers for Disease Control and Prevention. Multiple Chronic Conditions. August 2018.
  3. Association. Fast Facts: Data and Statistics about Diabetes. Revised December 2015.
  4. American Heart Association. Understand Your Risk for Heart Failure. May 2017.
  5. Ibid. National Center for Health Statistics. March 2017.
  6. Ibid. Heart Disease Fact Sheet. August 2017.
  7. Ibid. COPD Costs. February 2018.
  8. Results based on 2017 UnitedHealthcare book-of-business savings from the combined Disease Management programs and additional studies.
  9. UnitedHealthcare analysis of high-cost claimants, 2011–2016.
  10. UnitedHealthcare analysis of high-cost claimants, 2011–2016.
  11. UnitedHealthcare. Internal analysis of fully insured clients with both medical and pharmacy benefits. Fiscal year 2017.

Disclaimer

Tier 1 providers may be subject to change, visit myuhc.com® for the most current information or call the number on your health plan ID card.

The UnitedHealth Premium® designation program is a resource for informational purposes only. Designations are displayed in UnitedHealthcare online physician directories at myuhc.com®. You should always visit myuhc.com for the most current information. Premium designations are a guide to choosing a physician and may be used as one of many factors you consider when choosing a physician. If you already have a physician, you may also wish to confer with him or her for advice on selecting other physicians. You should also discuss designations with a physician before choosing him or her. Physician evaluations have a risk of error and should not be the sole basis for selecting a physician. Please visit myuhc.com for detailed program information and methodologies.