Managing Health Care Costs and Chronic Disease With Value-Based Care

The cost of chronic disease continues to rise, and employers feel that strain. Value-based approaches to care delivery can improve the health of your employees — and those with chronic conditions in particular — while controlling your health care costs.

Prevention and chronic care management are key to lowering costs for patients with chronic conditions. Preventive care, such as cancer screenings, helps doctors catch problems before they become chronic conditions. Employees in value-based health plans are more likely to receive preventive care, more likely to take their medication as directed and more likely to accurately follow a care plan than patients in fee-for-service plans.

Take, for instance, research published in the New England Journal of Medicine in 2019. Researchers assessed health and spending among several hundred thousand members of Blue Cross Blue Shield of Massachusetts whose doctors participated in a value-based program. Researchers then compared that data to that of a group of privately insured enrollees. The percentage of enrollees who met the criteria for quality care with respect to chronic disease management (e.g., diabetes care) improved from an average of 81% pre-AQC to 88% after; during the same period, New England (85%) and national (79%) averages remained unchanged.

Anthem’s Enhanced Personal Health Care program, a patient-centered, value-based care program, also showed positive results. Overall, it achieved a 3.1% improved compliance rate for diabetes screenings. Avoidable ER visits dropped 7.6%, leading to savings of 8.8%. Value-based care made care management realistic for more people, creating opportunities to improve factors such as adult BMI assessment, medication adherence and blood pressure control management.

But ensuring that patients have access to high-value care takes some work before it can become a reality. Here are the tools that providers, employers and employees are using to tackle high health care costs.

Risk Stratification

Not all patients need the same level of intervention. Risk stratification gives doctors insight into who needs the most attention — generally, people with chronic diseases and those at risk for them — and why.

That may work for an individual patient, but how would a doctor achieve that across an entire patient population? Comprehensive data plays a role here as well: Data-driven predictive modeling helps identify risk factors for patients with chronic diseases. Doctors can use this information to see which patients with diabetes are likely to visit the ER or be admitted to the hospital and then respond accordingly. Using evidence-based clinical guidelines, that data indicates where there may be gaps in care. The more data that is available, the more precise the predictions can be.

Anthem’s integrated data warehouse, for example, includes data from claims, electronic medical records and other sources. Using that data, providers — and Anthem — can identify which patients are most at risk for a stroke, diabetes or other condition.

Managing the Health of Populations

Population health management efforts are becoming more popular as value-based care gains prominence. A population health management program uses data to identify patients and categorize patients into groups — the practice then monitors and provides appropriate care to each group. The goal is to identify at-risk groups of patients with similar needs and step in with medical services that will reduce their use of costly care later on.

For patients with chronic conditions, for example, doctors would focus on care specific to chronic care management. With the right data, a practice can immediately see which patients have recently had a heart attack but haven’t been screened for depression, which patients with diabetes have untreated hypertension or which patients with hypertension have not been screened for diabetes.

Team-Based Care

A team-based approach creates space for the right professional to see the right patient. Say that Mary has just been diagnosed with diabetes. Her doctor could spend an hour explaining what she needs to do to manage her condition. However, a more efficient approach is to have a health coach or diabetes educator on the team. That professional is better equipped to address issues and answer Mary’s questions — and all at a lower cost than a physician.

Mary is more likely to stick to her care plan, because she’s an active partner in her care who’s working with her team, which may include a health coach, nutritionist and diabetes educator, in addition to her doctor. She’s more likely to stay healthy, because evidence-based protocols are in place to ensure optimal care. Meanwhile, doctors have more time to spend with acute patients — the people no one else on the care team is equipped to deal with.

Prevention and Mitigation

Ideally, patients would be able to prevent chronic diseases before they start. Since that’s not always possible, catching these conditions at an earlier stage, when they are less expensive to treat, is essential.

Let’s return to Mary: Identifying her diabetes early helps her better manage her health. Regular nutrition classes and blood tests are far less expensive than ending up in the ER with hypoglycemia or having a foot amputated, and they’re also much, much better for Mary’s well-being.

And for you? Your employees are healthier and more engaged when they — and you — pay less for coverage. Ultimately, everyone can benefit from figuring out how to lower health care costs and focusing more on getting value out of employee health care.

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