By Steven Ross Johnson, Modern Healthcare | July 21, 2018

In 2016, Magellan Health launched an initiative aimed at preventing suicide among its Medicaid beneficiaries in Maricopa County, Ariz. The results have been remarkable—suicides fell 67% in the first three months.

The managed-care organization achieved that by not only providing behavioral health screenings and faster referrals to mental health services, but by addressing some nonclinical factors like poverty, food and housing insecurity, and environmental exposures such as homes with lead paint.

Magellan wanted to see if solving those problems could affect behavioral health conditions such as isolation, prolonged stress and substance abuse—all of which can lead to suicide.

“We actually did things like buying air conditioners and delivering meals,” said Dr. Seth Feuerstein, Magellan’s chief medical officer of medical and digital innovation.

For-profit Magellan isn’t alone in addressing problems that previously were not tasked to healthcare organizations. In an effort to lower spending and improve patients’ lives, payers and providers are becoming increasingly responsible for a community’s overall health.

But insurers have always had an advantage given their access to information that follows the patient outside of the doctor’s office.

And now, more insurers are leveraging that information to help their bottom lines. According to a recent Change Healthcare survey, 42% of payers are adding community programs and resources to their population health efforts. Another 34% of payers said they use census and socio-economic data along with clinical data to create new programs.

Over the past decade, Magellan has covered the cost of mental health screenings at federally qualified health centers across several states. Those patients’ data, along with some local demographic and community-based information, helped pinpoint high-risk areas and the common factors residents in those areas were facing that might have increased patients’ risk for suicide.

Feuerstein said Magellan now truly understands how best to address those problems for their patient populations. That has helped Magellan fine-tune its strategies and better target its spending.

Health Care Service Corp., which operates large Blues plans, has been analyzing data as part of its population health strategy for nearly a decade, but its efforts have ramped up in the past two years as they try to address healthcare gaps among members.

For example, HCSC uses data to identify neighborhoods where patients don’t have cars, access to public transit or nearby primary-care clinics. Instead they tend to frequent local emergency departments. That information led the insurer to develop a pilot program that would help patients in need get primary-care appointments either by using a ridehailing service or by bringing services to them.

“As we look to strengthen quality improvement and member satisfaction, we really began to build some new muscle memory and develop a different approach to understanding some of those challenges,” said Dr. Derek Robinson, vice president of quality and accreditation at HCSC.

Analytics to prioritize interventions

The insurer also recently developed a performance reporting and analytics tool that will be rolled out to in-network clinicians in all of its plans next year. Robinson said the tool will feed data that helps providers see which patients might be missing certain screenings or medications, and prioritize the interventions they may need.

“Being able to do that is very critical to the ability to manage the health of a population,” Robinson said.

Robinson said the insurer over the past two years has used data sets from across different industry sectors that payers typically don’t review. That includes data on environmental quality, socio-economic status, level of education, a community’s walkability, and access to fresh food.

HCSC adds its claims and outcomes data to information from the Census Bureau and local and state public health departments to help identify prevalent social determinants of health within geographic areas.

“We can really look at all these different things down to a city-block level,” Robinson said.

The same Change Healthcare survey found that payers are using various techniques to engage patients in their own wellness efforts. For example, 48% of payers use wellness coaches, 36% use telehealth, 27% use patient navigators and 12% use text messages. About 25% of payers offer incentives to members who display healthy behaviors.

Those initiatives can lead to huge dividends. A study published last month in Preventive Medicine found that population health management efforts helped reduce heart attacks across a community of 4,000 adults in Minnesota.

Robinson said such results will only spark insurers to double down on their efforts.

“I think in the insurance industry we don’t want to be myopic in our approach,” Robinson said. “There are going to be some opportunities where we may see a return on investment that occurs much sooner than in other areas where the return on investment may take many more years to manifest.”

With more hospitals and health systems getting into the game of population health management, insurers are seeing new ways to partner with providers. The Change Healthcare survey found 23% of them already have created provider-payer programs to boost patient engagement.

Closing the gaps

“We’re starting to look at true gaps in care that we need to close,” said Caraline Coats, vice president of value based strategies for Humana. From a physician perspective, Coats said that means understanding what’s needed on a daily basis to consider social and environmental aspects of health within the clinical setting. That could come through prompts in an electronic health record or phone numbers to local resources.

Coats runs Humana’s 3-year-old Bold Goal initiative, which seeks to improve the health of their Medicare members by 20% by 2020 through a host of public health programs in 12 cities throughout the country. The effort targets social determinants of health with a special focus on food insecurity, loneliness and social isolation because of how those factors directly affect the number of a person’s “healthy days”—determined through a four-question survey tool developed by the Centers for Disease Control and Prevention that gauges a person’s physical and mental health state over the past 30 days.

Through the Bold Goal initiative, clinics in Broward County, Fla., for example, screened members for food insecurity. In 2016, they found close to half of patients, 46%, screened positive. People who are food insecure are 50% more likely to be diabetic, according to a 2014 study in the journal Current Nutrition Reports. The not-for-profit organization Feeding America found food insecurity is also closely tied to depression.

Humana partnered with Feeding South Florida to help address food insecurity in Broward County, Fla. Humana employees here are stocking emergency food boxes.

Humana estimates that an unhealthy day costs $15.64 in additional medical care per person per month. In 2017, the insurer saw the number of healthy days grow among its members in four markets participating in the program—San Antonio, Louisville, Ky., Tampa Bay and Broward County, Fla., and Baton Rouge, La.

But helping clinicians more easily identify social determinants is only part of the solution. Patients need tools and services to address their problems and that takes coordination not only between payers and providers, but also with community stakeholders who provide aid.

“There’s a balance as to how much the physicians should be involved and how much can be done through other methods,” said Dr. Roy Beveridge, chief medical officer at Humana. “That’s one of the things that we’re trying to figure out.”

Bold Goal has forged partnerships with local not-for-profit organizations, government and business leaders to address social determinants that affect depression and diabetes. One collaboration involves members of the Boys and Girls Clubs of the Tennessee Valley providing healthy cooking demonstrations to seniors in assisted-living centers in Knoxville. In that program, the number of unhealthy days among diabetic seniors went from 16 days in 2015 to 14 days in 2017. Humana also looks at some short-term measures to determine success, such as reduced ED visits.

But for insurers like Humana, the ultimate objective of population health management may not be achieved for a long time. “If we can demonstrate a clinical improvement in terms of what we’re doing, then we’re willing to wait a much longer period of time to see the economic return on investment because we know that will come,” Beveridge said.

Penalty risk?

To date, health insurers have used population health management efforts to create wellness programs and initiatives, but big data in the past has been used against consumers to increase premiums. Patient advocates worry that just as information that flags good behavior leads to incentives, bad behavior could result in penalties.

Analytic tools such as the ones used by HCSC and others provide information that could aid insurers in making policy decisions that save them money by denying care to patients.

The Affordable Care Act barred insurers from rejecting customers who had pre-existing medical conditions. If Republicans in Congress succeed with their push to lift that ban, insurers may look for signs in their data sets that would give them reason to refuse to pay for healthcare.

Magellan’s Feuerstein acknowledged such concerns, but contends the future of population health lies in the ability of payers to more effectively provide patients with a more comprehensive view of their own health. He believes a more knowledgeable consumer will help achieve payers’ goals of lowering costs by reducing the need for some healthcare services.

“Hopefully we will be better able to show them the value that we bring to them as they navigate the health system by empowering people to be able to make the choices that are right for them” Feuerstein said.