HEALTH PLANS Authors: Scot McConkey, Jordan Battani

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1 INTEGRATED HEALTH MANAGEMENT FOR HEALTH PLANS Authors: Scot McConkey, Jordan Battani Introduction The frustrations, delays and disagreements that have defined the United States debate on health care reform have had at least one very positive effect: there is now widespread agreement that health care in the United States continues to be too expensive, and does not deliver enough value in terms of quality outcomes to warrant the cost. Unfortunately, it doesn t look like the debate is producing a similar consensus on what must be done to fix these problems. Despite the lack of legislative or regulatory direction about solutions, it s clear that U.S. health plans must make successful efforts to reduce costs and to improve the quality and efficacy of the health care that s delivered. Relying on the administrative cost reductions that can be achieved through operational efficiency continues to be important, but it s not sufficient. Solving the health care cost problem requires health plans to operate at maximum efficiency and to address the underlying factors that drive health care cost. 1 Health plans must transform their approach to medical cost management in order to make it effective, and deliver sustained high-quality care at an acceptable cost. The key to this transformation is to employ a more thorough and integrated approach to control health care costs: employing traditional medical management competencies within the context of an end-to-end wellness management lifecycle that includes disease management, chronic disease care, case management, wellness and self-care management. Once an integrated health management program is in place at the health plan, the next step is to coordinate and integrate the wellness activities of home, workplace and health care settings. Finally, the results from these integrated interventions can be used to inform other health plan activities and interventions outside the boundaries of health management, and they can be supported and reinforced by benefit design and administration that ensures appropriate services are available and aligns the incentives of all participants for their most effective use. Health care cost pressures are real, and they are here to stay. Achieving fully integrated health management that addresses the health care costs of lifestyle factors, chronic disease and high-cost interventions must begin now. The first step is to address the health management lifecycle within the health plan by deploying a health intelligence approach to support the information and integration that will be required to rationalize and optimize current care management processes. As the internal processes mature, health plans must continue to improve their outreach and integration by mobilizing health intelligence to support engagement of external stakeholders and their information in extending the care management lifecycle beyond the walls of the health plan and into the workplace, home and community. From Medical to Integrated Care Health care cost inflation rates have proven to be remarkably resistant to change, consistently outpacing general inflation for at least a decade. 2 Traditional approaches to health care cost management, in the form of restrictions on provider payments and utilization, have sometimes been effective in the short run, but that success has generally been followed by periods of backlash after which health care costs begin to rise again. 3 Integrated Health for Health Plans 1

2 More recent innovations that increased consumer responsibility for cost and expense decisions associated with their have achieved modest cost reduction results in some market segments. While it s not clear that those results are extensible to the general consumer population, these programs demonstrate that for some consumers direct participation and access to tools and information that can be used to make care and utilization decisions produces impressive cost reductions. In the wake of these failures and disappointments, health plans have turned to a variety of care management solutions designed to address the health care consumption patterns of consumers on a variety of different dimensions. These solutions fall into four broad categories: 4 Wellness and Lifestyle interventions are designed to support the generally healthy before they exhibit symptoms of chronic or catastrophic disease. Disease programs require the identification of population sub-groups that are already exhibiting some elements of chronic disease. Interventions are less individualized and tend to address the characteristic of the larger population with risk factors. Case addresses the specific needs of individuals with active or acute illness. These services are more individualized and generally address the requirements of an acute episode of illness. An especially complex, catastrophic or costly episode may require the use of even more intensive case management tools often including the use of specialized networks of providers and services. End of Life programs address the treatment and cost decisions at the end of life when case management and catastrophic case management are not appropriate. The most familiar example of end of life programs is hospice. Health plans meet these program requirements in a variety of ways relying on a patchwork of internally developed applications, vendor solutions and outsource providers. 5 Vendor solutions, especially those that are outsourced, often target a particular disease or type of catastrophic case. This fragmentation is mirrored in the silo d organizational and work processes that health plans build to use the tools and manage the vendor relationships. One feature that is common to every element of the portfolio is the reliance on data from the health plan s source systems to identify the candidates for programs. Typically, each element in the care management portfolio has a proprietary approach to the extraction and optimization of source data, and the analytics that are required to transform the raw data into information that populates the solution. Few provide the ability to bring the resulting information back into the health plan, which limits the ability to integrate the results and interventions across programs much less to make them extensible to other care providers and health management partners that are external to the health plan. Figure 1. Care Portfolio Wellness Program (Employer 1) Wellness Program (Employer 2) Transplant Case End of Life Lifestyle Program Wellness Program (Employer 3) Specialty Network Case Disease (Diabetes) Disease (Asthma) Data Store Claims Benefits Membership Utilization Health Risk Assessment = Proprietary Data andintelligence Services 2 Integrated Health for Health Plans

3 What results is a patchwork of data extracts and reconciliation issues that are costly to build and inefficient to maintain. Data integrity can be a major problem because reconciliation across and among data requirements of various programs is difficult. The fragmentation of the care management portfolio can have poor consequences for quality of care as well. It s not unusual for a health plan member to be enrolled and engaged in many different components of a health plan s care management program, with little integration or coordination of interventions and results from one program to another within the health management continuum. Under these circumstances, it s almost impossible to imagine a scenario in which the outputs of a health management program could be used to inform work processes in other areas of health plan operations like customer service, or value based benefit design. A Framework for Integrated Health Health intelligence, like business intelligence, which it resembles, 6 is an enterprise-wide approach to the management of health information that addresses the lifecycle of the data across the continuum of integrated care management activities and outputs. It starts with the data management, services and architecture that are required to populate the systems and inform the work processes of the portfolio of care management activities. This foundation allows the health plan to rationalize the various processes, analytics and data optimization that each component of the care management portfolio requires, and to lay the ground work for comprehensive management and coordination of the inputs and outputs of each portion of the care management continuum. It s more than data and information management tools and technology however, because effective use of health intelligence requires the reevaluation and rational - ization of work processes and work flows to make most effective use of the data and information resource. When integrated health management is fully operational the outputs of the care management processes can be incorporated back into health plan work flows and processes both within the health management continuum and across traditional boundaries into other operational areas. New processes result and new governance structures are required as traditional silos, both functional and informational, are integrated and coordinated results are produced. 7 Figure 2 provides an illustration, and major components of the solution. Figure 2. A Framework for Integrated Health OVERALL PROGRAM STEWARDSHIP HEALTH MANAGEMENT SOLUTIONS Lifestyle Wellness Disease Care End of Life Queries OLAP CORE BUSINESS INTELLIGENCE SERVICES Process Models Statistical Analysis Data Mining Optimization FOUNDATIONAL DATA SERVICES Database Systems Data Architecture Data Models Metadata Data Collection Data Integration Data DATA SOURCES Claims Benefits Membership Utilization Health Risk Assessment Foundation Data Services Data services and architecture provide the foundation for the health intelligence solution that supports integrated health management. This is where data from disparate sources (which eventually include external sources as well) is transformed into an internally consistent and reliable data model that can be consistently enhanced and refined for reuse across 3 Integrated Health for Health Plans

4 multiple systems, settings and purposes. Using industry standards, tools and technology, the data services also include data management and security functionality that ensure confidentiality and privacy protections. Core Health Intelligence Services Health intelligence services are key to the transformation of care management into integrated health management. Standardized services are used to transform the data for use in the integrated health management processes and applications. Using a variety of standard tools the health plan can replace the idiosyncratic and proprietary data and information requirements of care management applications and processes with standardized and configurable solutions eliminating inefficiency, inaccuracy and duplication. Integrated Health Solutions Point solutions, processes and applications from the fragmented portfolio of specific care management interventions are integrated into health management solutions (initially internally, but eventually extending to external stakeholders and participants in health care delivery, workplace, community and home). Program Stewardship Transforming data into information, rationalizing work processes and achieving integration across silo d organizational boundaries requires consistent leadership, planning, evaluation and structured implementation. Establishing appropriate and effective governance structures and processes is key to the implementation process and ongoing effective operation of health intelligence and integrated health management. Engaging and Supporting External Stakeholders As health plans pursue the transformation efforts that will deliver integrated health management efficiencies, cost savings and quality improvements, they will need to begin to integrate with the efforts and resources of other stakeholders in the health management continuum. Health information processes and technology can be extended to include those of providers and institutions that plan, coordinate and deliver care, employers and other organizations that purchase care and promote wellness and health and perhaps, most important, individuals who make choices and pursue activities that effect their own health, lifestyle and wellness. The basic integrated health management framework outlined above must be expanded to account for additional data sources, including medical records information, laboratory results and other diagnostic information, workplace and community wellness programs, and others. Engaging and integrating with the efforts of other stakeholders will cause the expansion of health management solutions that are supported by the framework and the feedback mechanisms that ensure that each new finding, the successful interventions and the failures, are included in the data and information used to inform the next step in the integrated health management process. Foundational data services must be adjusted to account for a broader array of input and output requirements, increasing requirements for real-time and near-real-time access to information, as well as greater pressures on security and privacy controls. Core health intelligence services must be enhanced to provide the analytics, predictive modeling and other support for a wider array of demands and narrower timeframes in which to meet them. Robust and flexible governance will be required, as expansion will place pressure on data, technology and work processes as the health plan extends integrated health management across the spectrum of internal business processes, and positions itself as a node in a much larger framework of health management efforts and interventions that take place across the continuum of home, community, workplace and traditional health care delivery settings. Getting Started Implementing a robust integrated health management framework supported by health intelligence processes, tools and technologies is a large-scale, long-term set of activities, and like other business intelligence implementation efforts, it can be difficult and expensive. 8 4 Integrated Health for Health Plans

5 Best practice suggests focusing on the support for integrated health management within the health plan first, and extending capabilities to external stakeholders as resource availability and business priorities dictate. 9 The good news for health plans is that focusing on supporting integrated health management will serve to limit and refine the scope of initiatives and priorities, which is often a problem in complex business intelligence implementations. In addition, many plans have one or more components of the integrated health management framework in place already. Care management programs and applications are in use across the health plan sector and many of them are supported by a significant level of data services infrastructure. These pre-existing elements are good candidates for leveraging into the new solution. The biggest challenge is likely to be the implementation of the health intelligence layer of the framework, as this is likely to be the area in which most health plans will have relatively fewer elements already in place. Here again, the focus on supporting the integrated health management framework, as well as the need for existing programs, applications and processes, will provide guidance for priorities and requirements. Conclusion Some features of the health care landscape are undergoing profound change, health care cost reduction and efficiency improvement remain key focus areas for health plans. Successful health plans will be the ones that master the underlying causes of health care cost inflation. Transforming existing medical and care management processes into an integrated health management program is a good place to start. Existing programs are fragmented and deliver inconsistent results. An integrated health management framework, supported by processes, technology and tools will be critical to resolving that fragmentation and delivering consistent, sustainable improvements. Physicians, employers, other purchasers and consumers themselves are key players in integrated health management and health and wellness improvement that will lower costs on a long-term and sustainable basis. As health plans transform internal health management processes they must also begin to leverage the investments and successes to engage stakeholders outside the organization as well. About the Authors Scot McConkey is a Senior Partner and Managing Director of the Health Plan practice in the CSC s Healthcare Group. Jordan Battani is a Principal Researcher in CSC s Emerging Practices Group, the applied research arm of CSC s Healthcare Group. For more information contact us at healthcaresector@csc.com or Integrated Health for Health Plans

6 References 1 Battani, Jordan. Next Generation Health Plan. CSC, March (Accessed January 5, 2010). 2 Health Care Costs: A Primer. Kaiser Family Foundation. March Kaiser/HRET Employer Health Benefits Survey (EHBS). Kaiser Family Foundation. September What is Care? URAC. (Accessed January 5, 2010). 5 Outcomes guidelines, Volume 4. DMAA The Care Continuum Alliance, (Accessed January 8, 2010). 6 King, Rachel. Business Intelligence Software s Time is Now. Business Week, March (Accessed Januaray 11, 2010). 7 Foltz, Dan and Turisco, Fran. Health Intelligence for Performance-Driven Hospitals. CSC (Accessed November 24, 2009). 8 King, Rachel. Business Intelligence Software s Time is Now. Business Week, March (Accessed Januaray 11, 2010). 9 Foltz, Dan and Turisco, Fran. Health Intelligence for Performance-Driven Hospitals. CSC (Accessed November 24, 2009). 6 Integrated Health for Health Plans

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