Innovation’s Role in a Holistic Approach to High-Cost Claims
November 2019
Vincent Nelson, M.D., Vice President, Medical Affairs, Blue Cross Blue Shield Association
When someone mentions “healthcare innovation,” it’s common to think of technology. Taking a broader view, healthcare innovation can also be a strategic problem-solving approach to manage costs while improving health outcomes and providing a better employee experience. Addressing high-cost claims (HCCs) is one such example. HCCs are the number one cost driver for 43 percent of large employers, with the average bill adding up to $122,382 annually.1 Some of the drivers of HCCs include:
- Rapid introduction of new specialty drugs
- Rise in advanced treatment options
- Increase in patients with chronic and complex conditions
- Aging population
- Increased trend of mental health comorbidities
- Removal of annual lifetime maximums
Data-driven insights guide meaningful actions where they're needed most
While HCCs are a significant driver of healthcare costs, individuals with high-cost claims comprise just over one percent of employees.1 To identify and provide care intervention for those few employees who may require significant treatment, deep data is critical for sophisticated and precise analytics and predictive modeling. For example, Blue Cross and Blue Shield companies are drawing from our robust claims data, as well as socioeconomic data, electronic lab results, and health assessment data to predict, identify and stratify high-cost members.
Rich data also fuels high-touch strategies that pair process with personalized care and patient advocacy. For example, Highmark Blue Shield uses analytic triggers to identify health plan members who have complex needs, and then manages these members through a person-centered program that includes a nurse care manager who works one-on-one with the patient. A multidisciplinary team is readily available to the nurse care managers as they coordinate the member’s care. The Enhanced Community Care Management (ECCM) program meets the patient where they are—at home, the doctor’s office or hospital, or through virtual outreach and phone check-ins.
"As we built up trust, he began to know that he could call me so we could try to fix the issue before he ended up in the ED."
— Kelley Fishovitz
ECCM Nurse
Allegheny Health Network
A nurse in the ECCM program, Kelly Fishovitz, describes how one patient had been to the emergency department 12 times in one year. After talking with him and building trust, she put services in place to help him attend his regular appointments, including making sure someone would look after his elderly father while he was at the doctor.
“As we built up trust, he began to know that he could call me so we could try to fix the issue before he ended up in the ED,” said Fishovitz. “He’s healthier, he’s taking his medications and … he’s made big improvements in being able to manage his own care.” The patient’s ED visits also went down from 12 to seven in their first year together.
ECCM also improves communication and streamlines coordination of care across all providers. Just two years after its launch, total medical costs shrank 10 to 15 percent while inpatient admissions decreased 30 percent for Highmark health plan members in the program.2
A comprehensive strategy for managing high-cost claims
To better manage your employees’ health, deliver a positive experience and mitigate the risk of high-cost claims, it’s important for employers to understand how their health plan partner is using data and innovative thinking across the continuum of care in order to:
- Build a culture of preventive care. Proactively engage all employees to be good caretakers of their own health.
- Predict and identify risks. Flag potential HCCs before they happen via data-driven analytics and sophisticated modeling.
- Intervene early. Engage high-risk employees, help coordinate their care and better manage their medication to prevent escalation.
- Personalize care management. Support close coordination between patients and providers across the care continuum, as well as care management teams and caregivers, to ensure employees are at the center of their care and are receiving what they need when they need it.
- Manage cost and ensure payment integrity. Validate claim accuracy and identify healthcare waste and overuse with stringent reviews prior to and after payment.
Vincent Nelson, M.D., Vice President, Medical Affairs
Vincent Nelson, M.D., is vice president of Medical Affairs in the Office of Clinical Affairs (OCA) for the Blue Cross Blue Shield Association (BCBSA), a national federation of 36 independent, community-based and locally operated Blue Cross and Blue Shield (BCBS) companies. Today, one-in-three Americans are covered by the BCBS system.
Dr. Nelson provides clinical leadership across multiples disciplines, including quality management, provider recognition, medical policy, innovations of service delivery and strategic market opportunities. He ensures that the OCA and BCBSA incorporate clinical guidance that aligns with market demand and positively impacts the quality of healthcare while maintaining BCBS System leadership with members, providers and stakeholders. Prior to BCBSA, Dr. Nelson was a senior medical director/market chief medical officer for the Central/West U.S. Region at United Healthcare, where he partnered with senior leadership teams to lead market level programs, integrate clinical functions and drive results for clinical affordability, quality and population health measures.
Previously, Dr. Nelson held the position of Assistant Professor in the Department of Anesthesiology, Critical Care, and Pain Medicine, at the University of Texas Health Science Center, McGovern Medical School in Houston, Texas. His interests and activities were in clinical care, teaching residents, and supporting department collaborations with industry sponsored pharmaceutical and medical device clinical trials. Before his careers in academia and industry, Dr. Nelson worked as a private practice clinician for 12½ years. He was a founding physician partner and board member of United States Anesthesia Partners (USAP).
Dr. Nelson obtained his bachelor’s degree in biological sciences from Stanford University. He holds a master’s degree in business administration from Rice University, Jones School of Business, and a medical degree from the University of Chicago, Pritzker School of Medicine. He completed his Clinical Residency and Fellowship training at Harvard Medical School, in the Department of Anesthesiology, Pain Management, and Critical Care Medicine at Massachusetts General Hospital, Boston, Mass.
© 2019 Blue Cross Blue Shield Association. All Rights Reserved. The Blue Cross Blue Shield Association is an association of independent, locally operated Blue Cross and Blue Shield companies.
1 D. Mark Wilson, Tevi D. Troy and Kara L. Jones, “High Cost Claimants: Private vs. Public Sector Approaches – Executive Summary,” American Health Policy Institute and Leavitt Partners, 2016. http://www.americanhealthpolicy.org/Content/documents/resources/High_Cost_Claimants.pdf.
2 https://www.highmarkhealth.org/blog/care/Enhanced-Community-Care-Management-A-Nurses-View.shtml.
