High Utilizers of Healthcare
High utilizers of healthcare are a small percentage of individuals who account for most of healthcare spending in the United States. Research has shown this as a steady trend over the years, and the Agency for Healthcare Research & Quality reports that 5% of the population accounts for 49% of total healthcare expenses. A report by the Government Accountability Office found that 5% of Medicaid enrollees made up 48% of costs, and a mere 1% of enrollees accounted for 25% of the costs. These figures identify a strong incentive for managed care health plans to develop comprehensive programs around supporting these members and ensuring that they are receiving the right care at the right time, as well as receiving the resources to properly manage their conditions.
Supplementing Care Coordination
To provide quality care to complex patients, managed care health plans are required to deliver care coordination services, either internally or by contracting with other organizations. These services include health assessments and management for members who have complex care needs, including multimorbidity of physical and behavioral conditions, along with social or environment considerations.
These programs are put in place to provide support and assistance for members that are identified to be high utilizers or at high risk of complications related to their condition and can include both telephonic support and even in-person visits if needed. While these programs are successful in providing an additional layer of support to the member and his/her family, they are limited in their capabilities to provide real-time monitoring and on-demand access to patient education.
A U.S. Department of Health and Human services report identifies that challenges that these high-risk populations face include the management of multiple chronic conditions, lack of health literacy, and barriers to access and engagement with care.
The Value of Telehealth
Today, telehealth platforms allow patients to self-monitor their vitals daily and answer questions on how their symptoms are progressing. Moreover, it allows clinicians to receive alerts if there are any high-risk readings and to be proactive about addressing them. Most importantly, telehealth helps empower patients and creates self-management habits.
Telehealth can also address health literacy gaps through educational videos available across a variety of disease conditions, which the patient can access to learn more about managing their condition. Many telehealth programs give patients easy access to any additional educational materials provided by their health plan or primary care provider.
Through telehealth, the patient has access to calling, video chatting, and text messaging with their clinician or care coordinator. Likewise, the clinician or care coordinator can reach out to the patient to check in if vital signs or symptoms are outside of parameters, allowing the care team to intervene and avoid a preventable ED visit or hospitalization. The ability to intervene, along with resources to promote self-management and access to educational materials, has the potential to cut down on unnecessary spending while also improving quality of care.
Health plans that already have a care coordination team in place could leverage those individuals to monitor patients’ vitals and alert primary care providers of any high-risk changes. Even health plans who are unable to support this type of operations in-house could partner with home health agencies or hospital systems who can monitor patients and keep both the care coordination team and primary care provider well-informed of the patient’s status.
Ultimately, the use of telehealth in managed care operations empowers a patient to learn more about their condition, promotes self-monitoring, augments a care coordinator’s reach, and allows for more actionable interventions by the patient’s primary care team to prevent unnecessary healthcare spend and improve quality of life.