What is Care Management?


Based on an analysis of Premise Health clients, over 60% of employers’ medical spend each year comes from only 5% of its insured members. Yet only 1 out of 5 of those members will become high-cost year over year. In order to explain this phenomenon, we have to look at some common cost drivers for these organizations. Generally, they fall into two categories.

First, there’s the member who is healthy and experiences a one-time, high-cost occurrence such as major surgery or a car accident, after which the member makes a full recovery and is low-cost the following year. On the other hand, you have the member who has multiple chronic conditions like diabetes, lupus, or hypertension, takes a variety of medications, and makes several trips to the emergency room throughout the year. This member is consistently high-cost year after year because their care is complex, and they may not have the resources to address their health issues in a sustainable way.

Providing convenient access to high-quality care for both types of members is vital. However, providing consistent, tailored care to people with high-touch needs can help employers see a long-term reduction in healthcare spending. That’s where Care Management comes in: to identify and support those members with personalized treatment plans. This solution provides the hands-on guidance they need to realize better health outcomes and an improved quality of life, reducing their reoccurring urgent care visits and bottom-line cost of care.

What is Care Management?

At its core, Care Management engages members who need support the most. This solution ensures high-cost, high-risk members receive holistic care to effectively manage their health and improve care gaps. Within Care Management itself, there are two approaches:

Care Management with claims data

Claims data can give important insight into a population’s health – including the number of frequent, costly hospital stays or urgent care visits. For Care Management, it’s the key to a proactive approach: when Care Managers are equipped with information around the sources of healthcare spend, they can identify, and reach out with tailored support for those high-cost, high-risk members. As a result of identifying these members on the front end, teams can strategically support employees and their dependents, eliminate barriers to care, and help employers understand how improving conditions impacts their bottom line over time.

Care Management without claims data

In this model, members managing chronic conditions can self-identify, get referred by a provider, or be identified by a provider via Epic to work with a dedicated care manager; members will get personalized education, guidance on how to change their habits, and accountability from an expert. Tailored solutions are provided for each member’s unique health situation by performing a thorough review of lifestyle choices and family histories to identify risk factors and design personalized care plans. Members feel empowered knowing they have a trusted partner they can count on throughout their care journey.

The Benefits of Care Management

By leveraging the insight Care Management provides, care teams can discover who to focus on, why they’re struggling, and help get to the root cause of their health issues. As a result, members can make informed decisions, be more invested in their healthcare journey, and experience higher levels of fulfillment. This will create lower overall costs and better healthcare outcomes by giving members the tools to take control of their health.

At the end of the day, when your people live healthier, you save more.

What can your members expect?

A seamless member experience is at the heart of this process with care managers proactively reaching out to your members to discuss all the great benefits at their disposal. They are trained to take a helpful, non-invasive approach and are equipped to navigate the sensitivity of discussing health information. The outreach is designed to be very conversational and inspires members to take a greater interest in their overall health. Personal accounts from our current members demonstrate the impact Care Management can have:

“[I appreciate] the care and research taken to help get my blood pressure under control, also making me feel at ease [that] I was not a failure because I needed pills to get it under control. Also, the help to get my weight under control with [the provider] helping with ideas and tips each month.” – Member in Colorado

Optimizing care for your population

Leveraging data to actively improve healthcare quality, experience, and value is crucial for Premise Health’s Care Management solution. Our innovative take on population health helps members access high-quality care while delivering significant savings for employers and optimal outcomes for members.

Learn how Premise Health can help optimize the care of your employees. Contact us today.


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