Skip to Main Content

 From the Trust Perspective: Does wellness matter? (Part II) 

by Bob Haynes, NCLM Associate Director, Risk Management Services

In my last article I discussed the free wellness exams available to members of our health pool and the new requirement that employees must have their appropriate wellness exam done or be assessed a 10 percent penalty for. Some complained that this was an unfair and intrusive requirement. However, as the statistics showed, many of our high claims could be tied to failure to get the screenings completed.

Now that the requirement is in place, we have seen a significant increase in the number of exams completed, but the really good news is it has saved at least two lives!

One person who complained that we should not have required the colonoscopy learned following her procedure that she had colon cancer that was on the verge of spreading to internal organs — the test was done in the nick of time, and the cancer is treatable as a result.

Another person went for his routine physical as a result of these requirements and was immediately taken to the emergency room as he was a heart attack waiting to happen. Again, the intervention was in the nick of time, and heart surgery saved his life.

These employees are now "very thankful" we instituted these requirements!

It is gratifying to know that we are accomplishing what we had hoped:1) Saving lives through early detection (even if it’s just in the nick of time)

2) Improving the health of our members

3) Enabling members to begin a relationship with a doctor for long-term health benefits; and

4) Saving money through the avoidance of costly, long-term treatments.

Moving forward we plan to implement predictive modeling to identify those individuals with the highest probability of high-cost medical claims. These are those folks who are about to develop a chronic condition such as diabetes or hypertension, as well as those who have already been diagnosed but are not managing their conditions. Software programs are available that will use medical and pharmacy claims data to identify these individuals, which allows us to then focus our wellness resources to the specific areas of need. We are excited that this will allow us to take a major step forward in helping our members positively manage their health.

Last Fall we had a preliminary analysis done of our claims. The results were not great, but the opportunities to better manage our costs are. For example, our overall costs are consistent with groups that are "loosely managed." If we can bring these costs down to the "moderately managed" benchmark we will save $4.8 million in claims (almost 10 percent). Additionally, these analytics will allow us to answer the question, "How are the ones we are tracking doing?" In 2013-14 we had just over $9 million in claims from modifiable conditions. Targeted interventions that bring down costs by 10 percent would save us $900,000. This is accomplished by avoiding ER visits and inpatient hospital stays as individuals better manage their health.

Please stay tuned as we implement predictive analytics, focus our efforts on saving lives and improve the health of our members as they better manage their conditions and ultimately save money resulting in lower rates.