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A Proactive Approach to Closing Care Gaps

Healthcare executives from across the nation descended on Tennessee for the RISE Nashville Summit in late March. RISE Nashville is a conference focused on risk adjustment, quality, and Stars for the Medicare Advantage and ACA markets.

While attending the conference, our team met with many innovative companies each with various solutions that drive profitable health plan and payer economics. Most companies in attendance focused on closing coding gaps using analytics, artificial intelligence, and machine learning. The solutions these companies offer help identify patients and members that require screenings and exams in order for health plans and payers to increase profitability.

To identify the patients with open care gaps (the true value in risk adjustment and Stars reimbursement) these solutions require large sets of claims and/or EMR data from the provider or plan. The companies then run analytics on the data and use techniques like machine learning for analysis, and to create lists of different coding gaps that the patients and members need to have completed. These care gaps can be anything from an annual wellness exam to an A1C screening to a mammogram.  What I observed is that, for the majority of attending companies, this is where their solutions came to an end.  Once the analytics identified members needing the numerous screenings and exams, the work to engage the patient or members to take action was left up to the payer or provider.

It did strike me that this is a reactive approach, and really must be complemented with a proactive strategy that gets people the care they need before there is a gap. These companies are pushing the boundaries of healthcare analytics, and there is a need for them in the market place, but for the majority of them, they do not finish the story with integrated consumer engagement.  At GuideWell Connect, we have a solution called “Member Activation” where we guide members through an experience that not only conveys the benefits of the plan to the member, but also gathers a quick health survey to identify people that need help with their care.

By keeping the experience simple and conversational, we have been able to achieve significant member participation, and find out early on (before their effective date in some cases) who needs to schedule a wellness exam or manage a condition by clinical guidelines.

When you can find out before their effective date that a member has diabetes, and is not managing their medications properly, you can reach out to the member at the start of the plan year and get them into a care plan before gaps in care occur. You can help educate that member on diabetes and help them understand that they need to get their foot assessment, A1C test, and an eye exam. For the members you can successfully “activate” up-front, you won’t risk waiting up to six months until their claims and EMR data are fed into a ‘big data lake’ to run machine learning analytics and finally identify they have gaps. You can catch that all up front…along with the reimbursement dollars.

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