Latest / Becker’s Payer Issues Podcast / Earlier Signals, Better Outcomes: Rethinking Risk Stratification for New Members

Transcript

Earlier Signals, Better Outcomes: Rethinking Risk Stratification for New Members · Becker’s Payer Issues Podcast

• 0:00
  - Hi, everyone. This is Brian Zimmerman with Becker's
• 0:02
  - Healthcare. Thank you so much for tuning into
• 0:04
  - the Becker's Healthcare podcast.
• 0:06
  - Today, we're gonna talk about rethinking risk stratification
• 0:09
  - for new members.
• 0:11
  - Joining me for this discussion is Carla Mills,
• 0:13
  - vice president of product innovation with SureScripts.
• 0:17
  - Carla, thank you so much for being here
• 0:18
  - today. It's my pleasure, Brian. Thank you.
• 0:21
  - So so to kick things off, can you
• 0:23
  - share a bit about yourself, your your professional
• 0:25
  - background, the work you're doing today with our
• 0:28
  - listeners so they can really appreciate where you're
• 0:29
  - coming from as we move through the conversation.
• 0:32
  - Of course. So as you said, I work
• 0:34
  - as a VP of product innovation here at
• 0:37
  - Surescripts, and my portfolio spans across our medication
• 0:40
  - history and our value based care.
• 0:42
  - My background spit spans both the clinical care
• 0:45
  - and interoperability
• 0:46
  - segments, and I've spent my career focused on
• 0:48
  - how we connect data into ways that actually
• 0:50
  - improve outcomes.
• 0:52
  - For those that are less familiar, Surescripts is
• 0:54
  - the nation's leading health intelligence network, and our
• 0:57
  - mission is to help health care heal itself
• 1:00
  - by connecting data in ways that improve outcomes
• 1:03
  - and make care easier to navigate. I spend
• 1:05
  - a lot of time thinking about how we
• 1:08
  - help health care heal itself. And let's be
• 1:10
  - honest, health is a journey. And for some
• 1:12
  - people, it's harder than others, and there are
• 1:14
  - lots of challenges along the way.
• 1:16
  - I I I love that phrase, helping health
• 1:19
  - care heal itself. Can you share a bit
• 1:21
  - more about what you mean by that?
• 1:24
  - Of course. When we think about all of
• 1:26
  - the friction points in health care both as
• 1:28
  - consumers and as clinicians,
• 1:30
  - it's important that we put the tools and
• 1:32
  - the information in in the right stakeholders' hands
• 1:35
  - at the right time.
• 1:36
  - And so that's part of our brand mission
• 1:38
  - when we think about Surescripts and we think
• 1:40
  - about how we apply ourselves
• 1:42
  - to being a leading health intelligence network.
• 1:46
  - Excellent. I appreciate you going going a layer
• 1:48
  - deeper there for us.
• 1:50
  - So you you've referred to what happens to
• 1:52
  - health plans in January as,
• 1:54
  - quote, unquote, blizzard season.
• 1:56
  - So when that new member wave hits, what
• 1:58
  - are the biggest challenges health plans experience during
• 2:01
  - that time?
• 2:02
  - As we sit here in a
• 2:04
  - in mid June, January feels far away, but
• 2:08
  - operationally, it's right around the corner. And for
• 2:10
  - health care and for health plans, that's really
• 2:12
  - how we think about it is that blizzard
• 2:14
  - season.
• 2:15
  - You take on that new influx of members,
• 2:18
  - and the reality is you don't have a
• 2:19
  - clear or timely picture
• 2:21
  - of who they are from a risk perspective.
• 2:24
  - And the biggest problems from our perspective come
• 2:26
  - down to time lag and fragmentation.
• 2:29
  - The claims data as they're processed and as
• 2:31
  - members seek care come in too late, and
• 2:33
  - the clinical data is incomplete or it's fragmented.
• 2:37
  - And while we're seeing progress with things like
• 2:39
  - payer to payer APIs and the upcoming one
• 2:42
  - one twenty seven mandates, there's still a gap
• 2:44
  - between policy and operational reality.
• 2:48
  - So if you're if you're sitting on the
• 2:50
  - health plan side and you're trying to prioritize
• 2:52
  - and risk stratify, but you don't have a
• 2:54
  - clean
• 2:55
  - and an early signal
• 2:57
  - set in order to do that well. That's
• 2:59
  - what we mean by blizzard season.
• 3:01
  - Excellent. I appreciate that definition.
• 3:04
  - And and so
• 3:06
  - thinking about that,
• 3:07
  - if if I'm a peer executive and and
• 3:09
  - you're getting these members that that are coming
• 3:11
  - through that we we kinda don't understand or
• 3:14
  - don't really know,
• 3:16
  - they're they're unfamiliar
• 3:17
  - to us. Right? What's the simplest way to
• 3:19
  - think about medication signals?
• 3:22
  - Can you share an example of a member
• 3:24
  - you flagged earlier through medication patterns and and
• 3:27
  - why that proactive approach is so valuable.
• 3:30
  - You frame this up really well, Brian,
• 3:32
  - because we we think about this as a
• 3:35
  - early leading signal
• 3:37
  - that gives that real time view of what
• 3:39
  - conditions and what delete
• 3:41
  - disease states are actively being treated.
• 3:44
  - For example,
• 3:46
  - at Shrescripts, we recently completed an analysis of
• 3:48
  - 20,000 patients,
• 3:50
  - pulling a random sample set of
• 3:53
  - of people ages 35 to 65 and looking
• 3:54
  - at prescription history as a signal for that
• 3:55
  - disease burden.
• 4:03
  - Common
• 4:06
  - chronic conditions, diabetes,
• 4:07
  - hypertension,
• 4:09
  - hyperlipidemia,
• 4:10
  - and respiratory disease,
• 4:12
  - and then, pushed ourselves further to look at
• 4:15
  - another dimension and some additional comorbidity
• 4:17
  - conditions
• 4:18
  - that influence outcomes and total cost of care.
• 4:21
  - So for that second,
• 4:24
  - condition set, think about behavioral health, oncology,
• 4:28
  - chronic pain, or even dermatology.
• 4:30
  - And so as we looked at that, what
• 4:32
  - was really telling is just
• 4:35
  - the the state of where we are at
• 4:37
  - for health in The United States.
• 4:39
  - Sixty seven percent of those members had at
• 4:42
  - least one chronic
• 4:44
  - condition.
• 4:44
  - And we saw that through the prevalence of
• 4:46
  - use and what medications were actively filled and
• 4:50
  - at that patient's fingertip.
• 4:53
  - Additionally, we saw almost eighty percent of that
• 4:56
  - same sample set had an additional comorbidity.
• 4:59
  - And so if you're looking across both condition
• 5:01
  - sets,
• 5:03
  - we found that fifty six of them had
• 5:06
  - both
• 5:07
  - a chronic condition as well as a as
• 5:10
  - a secondary comorbidity
• 5:12
  - condition that influenced what their outcomes are. And
• 5:15
  - that's the real takeaway,
• 5:17
  - is you can see who you're managing from
• 5:19
  - a multiple interacting
• 5:22
  - comorbidities and risk perspective, not months later as
• 5:25
  - the claims come flowing in and as
• 5:28
  - as the health plan benefits are being used,
• 5:31
  - but right away. And so that's the macro
• 5:33
  - layer. And if we come down, and I
• 5:35
  - heard this in your second as well, a
• 5:36
  - layer further and talk about just a simple
• 5:39
  - example.
• 5:40
  - If you see a new member that has
• 5:42
  - a fill for a statin, an antihypertensive,
• 5:45
  - and something that's for depression, anxiety, or chronic
• 5:49
  - pain, you're just not seeing three medications.
• 5:52
  - You're seeing cardiovascular
• 5:54
  - risk layered with behavioral
• 5:56
  - behavioral
• 5:57
  - or physical health,
• 5:59
  - and and you're identifying someone that you want
• 6:01
  - to engage early on and know that you're
• 6:03
  - gonna have,
• 6:05
  - potentially some other challenges you have to work
• 6:07
  - through when you think about care that's meaningful
• 6:09
  - for the member.
• 6:10
  - Now I'm the first one to say that
• 6:12
  - medication data isn't a perfect diagnostic tool, but
• 6:15
  - it's that really strong directional signal of emerging
• 6:18
  - risk and complexity.
• 6:20
  - Yeah. There's there's
• 6:22
  - it's not everything, but there's a lot there
• 6:24
  - that can be unpacked from that that medication
• 6:26
  - data.
• 6:27
  - And, Carlo, those numbers you shared are are
• 6:29
  - striking. Those are those are big numbers. And
• 6:32
  - so when you think about the the the
• 6:34
  - volume here, how how many patients are are
• 6:37
  - are fall into these buckets,
• 6:40
  - when you are getting to those patients,
• 6:42
  - as you said, in in a matter of
• 6:44
  - weeks versus months,
• 6:46
  - how does that sort of, I guess, impact
• 6:49
  - across care management pharmacy and population health?
• 6:53
  - Where where what results does that drive, and
• 6:55
  - what has to happen operationally for those
• 6:58
  - insights to get spread out and and drive
• 7:01
  - action?
• 7:02
  - And instead of just, like, living in a
• 7:04
  - dashboard, these become truly actionable insights that can
• 7:07
  - drive, I would imagine, based on the size,
• 7:10
  - some profound results for for the organization and
• 7:12
  - and and the patients involved.
• 7:15
  - We agree with those statements, of course. And
• 7:17
  - I think it really changes that
• 7:20
  - that proactive from reactive where even if it's
• 7:23
  - not weeks later,
• 7:24
  - this dataset allows
• 7:26
  - that operational leader in order to risk stratify
• 7:29
  - and prioritize on day one
• 7:31
  - rather than playing catch up on week three
• 7:33
  - or month four.
• 7:34
  - And it's all those things that I heard
• 7:36
  - you say. It's prioritizing members immediately.
• 7:39
  - It's guiding them into existing care management and
• 7:42
  - pharmacy programs. We're not we're not suggesting that
• 7:45
  - anyone needs to create anything new, but what
• 7:48
  - we are saying is you can align those
• 7:50
  - care gaps before they widen and as those
• 7:52
  - windows of intervention present themselves.
• 7:55
  - It also gives you a much clearer picture
• 7:56
  - of who's likely to fall into your stars
• 7:58
  - and heaters denominators.
• 8:00
  - And we know those measures are so, a,
• 8:02
  - heavily weighted, and b, so time sensitive
• 8:05
  - that it allows you to engage these members
• 8:07
  - before gaps turned into biggest opportunities.
• 8:10
  - And so
• 8:11
  - kind of recapping what we just talked through,
• 8:13
  - it's that operational pull through and that execution,
• 8:17
  - within your existing care and pharmacy programs. It's
• 8:20
  - that care management making sure you've got the
• 8:23
  - right priority and earlier and more targeted outreach.
• 8:26
  - It's the pharmacy with focus on intervention and
• 8:29
  - therapy optimization
• 8:31
  - and that that global population health that allows
• 8:34
  - you to do that segmentation and that stratification
• 8:38
  - upfront.
• 8:39
  - And I think that's the real gonna be
• 8:41
  - differentiator
• 8:42
  - as we think about health plans and who
• 8:44
  - does this well and who does this great.
• 8:46
  - An additional dataset allows you to optimize what
• 8:49
  - you have in in pretty staggering fashion.
• 8:53
  - Yeah. Be because what what what these plans,
• 8:56
  - what these organizations already have can be truly
• 8:58
  - impactful and meaningful. Right? It's just you've gotta
• 9:00
  - have the the the right information, the right
• 9:03
  - the right information, and then the right tactics
• 9:05
  - to to get people moving in the right
• 9:07
  - direction. Correct, Carla?
• 9:10
  - Yes. And no one wants to hear. Right?
• 9:11
  - You need to stand up a new program
• 9:13
  - or you need to start something new.
• 9:16
  - But if you can optimize what you have
• 9:18
  - and you can think about how to pull
• 9:19
  - how to do that in a more timely
• 9:21
  - fashion, then everyone wins.
• 9:23
  - Right. And and and I wanna come back
• 9:25
  - to Blizzard season as we close out here.
• 9:27
  - And as you mentioned, it might January might
• 9:30
  - feel far away, but I think, you know,
• 9:33
  - everyone can relate to this experience of having
• 9:35
  - those seasons, these busy seasons really creep up
• 9:37
  - on you. So,
• 9:39
  - for just, I guess, a practical, actionable way
• 9:42
  - to end this here,
• 9:43
  - if you had to give health plans just
• 9:45
  - a a three point June checklist to get
• 9:48
  - ahead of blizzard season, what would that be?
• 9:52
  - I love my checklist. So I think check
• 9:54
  - one is looking at your data strategy,
• 9:56
  - recognizing that claims and clinical data are wonderful,
• 10:00
  - but they're not enough for that early stratification,
• 10:03
  - and see them see claims in clinical as
• 10:06
  - those lagging indicators and push upstream on how
• 10:09
  - you can get more of that timely data.
• 10:11
  - The second is to start thinking about those
• 10:13
  - medication signals as that early input.
• 10:16
  - And, again, this is not about replacing what
• 10:18
  - you have, but it's about enhancing it and
• 10:21
  - helping you understand that risk,
• 10:23
  - understanding who your denominators are, and ensuring you
• 10:26
  - have that prioritization
• 10:28
  - right at onboarding.
• 10:30
  - And the third is that operational execution
• 10:32
  - and really challenging yourself in the organization to
• 10:35
  - say, how are you prioritizing numbers on day
• 10:37
  - one today? And how are you enrolling them
• 10:39
  - into your existing programs and pharmacy programs?
• 10:43
  - And can you do that earlier?
• 10:46
  - And then ensuring that those programs are set
• 10:48
  - up in ways that they can consume
• 10:51
  - those early indicators,
• 10:53
  - to do the work and the workflows that
• 10:54
  - are already defined.
• 10:56
  - Because as you said,
• 10:57
  - January feels far away, but,
• 11:00
  - it's not so far when you think about
• 11:02
  - buying season
• 11:03
  - and some new decisions and and pulling through,
• 11:07
  - additional value.
• 11:08
  - Yeah. Do your your future selves and your
• 11:11
  - future organizations
• 11:13
  - a favor in June and and and get
• 11:15
  - that checklist done and and be ready for
• 11:17
  - for blizzard season. Right, Carla?
• 11:19
  - Absolutely.
• 11:20
  - Carla, it's been great having you on the
• 11:22
  - podcast.
• 11:23
  - Before I let you go here, can you
• 11:25
  - maybe share one final thought with our listeners
• 11:27
  - today, whether that's something you wanna double down
• 11:30
  - on, reemphasize, or maybe it's something you didn't
• 11:32
  - get to share? But I'll leave it to
• 11:33
  - you throw it to you to close out
• 11:34
  - here.
• 11:35
  - Leaders in health care, we're all challenged to
• 11:38
  - how do we improve outcomes. And I strongly
• 11:40
  - believe, as part of that, we have to
• 11:42
  - move upstream
• 11:43
  - and think about how we solve problems and
• 11:45
  - not manage symptoms.
• 11:47
  - And so when we think about blizzard season,
• 11:49
  - you think about risk prioritization, it's really understanding
• 11:52
  - where you can move to real time signals
• 11:55
  - and making sure that those signals
• 11:57
  - are optimizing those programs and the work that's
• 12:00
  - already done. But
• 12:02
  - that's a concept and a vision that Surescripts
• 12:04
  - believes greatly in, and we're actively working on
• 12:06
  - ways to make medication data more accessible
• 12:09
  - to health plans and value based care organizations.
• 12:12
  - We have a lot of work underway right
• 12:14
  - now, including,
• 12:16
  - pilot terms and
• 12:18
  - and options,
• 12:19
  - as well as some additional capabilities that we'll
• 12:21
  - be sharing throughout the year.
• 12:23
  - As as I said earlier, this is something
• 12:26
  - that I believe strongly in, and and we're
• 12:28
  - all challenged to help health care heal itself.
• 12:31
  - Well, Carla, thank you so much for for
• 12:33
  - coming on the podcast.
• 12:34
  - We also wanna thank our podcast sponsor, SureScripts.
• 12:38
  - You could turn to more podcasts from Becker's
• 12:40
  - Healthcare by visiting our podcast page at beckershospitalreview.com.