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

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