Proactive Risk Stratification

With the data at our fingertips, we can identify those members who are high risk based on much greater detail than biometric or claims data alone. Using the data, we can drill down to identify such risk factors and answer such questions as the following, to name just a few:

  • What are the top diagnostic risk groups that are consistently driving the largest percentage of the plan’s claims?
  • Which members are expected to spend more than $15,000 in the next 12 months?
  • How many members are seeing more than 12 physicians in a 12 month period with no coordination between providers?
  • Which members have multiple prescribing providers that are not collaborating?
  • Which members have 3 or more of the 5 biometric risk factors resulting in Metabolic Syndrome (a leading indicator of certain disease and catastrophic claim risks often before the claims occur).
  • Which members are in compliance with evidence-based guidelines and wellness programs?
  • Which members are in compliance with case management and disease management programs?
  • Of the members who participated in employer wellness programs, how many improved their biometric and actual claims outcomes?
    • By how much?
    • How much money was saved as a result?
      The system allows us to flag specific groups of people and query or track their claims independently from the rest of the population—groups are unlimited and can be flagged based on wellness programs, geographical differences, divisions, etc.

With answers to these key questions, our teams are able to design customized programs. Our programs very selectively target the high risk individuals on your plan using proven behavioral science techniques to influence behaviors. Our programs are designed to reverse the rate at which high risk individuals manufacture disease, as well as slowing or reversing the risk factors of those considered to be “moderate” or “low” risk individuals.

Our goal throughout the programming development is to continually help you establish and implement priorities that focus resources on the areas that will have the greatest financial impact with the least amount of disruption possible.