MedCity Influencers, Consumer / Employer

The case for care management offerings for employer-sponsored health plans

Care management programs are well-positioned to help employers not only improve employee health and manage spend, but recommend needed care or next best steps, and influence behavior changes so adverse health events don’t happen in the first place.

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Employers have long been invested in the health of their employees, both as a good business practice and for the overall wellbeing of their associates. Promoting healthy behaviors is nothing new, but with rising healthcare costs, there is additional motivation to do so. Engaging employees in their health and offering individualized interventions can not only lower costs, but more importantly, improve their health outcomes.

The levers available to help motivate healthy behaviors have continued to evolve. Incentives like lower insurance premiums for enrolling in wellness programs, or penalties like surcharges for tobacco users, are examples of how employers can help facilitate positive behavior change both in and outside of the health plan – improving the health of their employees or preventing conditions from worsening.

Care management programs are a prime example of this. Targeted toward those with complex or chronic conditions, care management programs can help:

  • Lower overall healthcare costs
  • Improve quality of life
  • Enhance benefit packages
  • Aid in employee retention

Care management is not a new concept. But the healthcare system has changed. The Kaiser Family Foundation found that 91% of workers in the U.S. are employed by companies that offer health benefits to at least some of their workers. Care management programs are well-positioned to help employers not only improve employee health and manage spend, but recommend needed care or next best steps, and influence behavior changes so adverse health events don’t happen in the first place.

Challenges with deferred care

The Covid-19 pandemic caused delays in those seeking healthcare. Concerns about contracting the virus resulted in more than 41 percent of U.S. adults delaying or avoiding medical care. Delays in care might mean lower costs for employers now, but what happens later?

Mercer surveys found that employers expect a 4.7 percent increase in health benefits costs for 2022. They also stated that although deferring or cancelling care for the past two years may have led to lowers costs in the short term, it can increase costs over the longer term when medical conditions are diagnosed later or left untreated for too long. This is particularly challenging for those with rare or chronic conditions, which are typically less controlled and require a higher degree of medical care on average.

Care management programs offer employers a way to help ensure their employees with chronic conditions receive the care that they need. Additionally, because care management nurses employ multiple methods of communication, including phone calls, emails, letters and texts, employees can choose how they want to communicate, increasing the likelihood of them participating and engaging with the care management program. What’s more, because care management nurses support patients on an ongoing basis, they can quickly identify and help close gaps in care, as well as intervene when needed with targeted support, which helps improve outcomes and prevent adverse events. And they can share this information with the rest of the patient’s care team so everyone can make more informed, timely decisions.

Shifts in site of care

Employers and health plans were seeing a shift away from traditional brick and mortar sites of care even before the Covid-19 pandemic. The pandemic accelerated this change, and now, the way in which healthcare is delivered looks different. Whether it’s a shift to a virtual visit or phone call, our expectations aren’t the same.

But it’s not just doctor visits that are changing. Previously, living with a chronic condition could mean multiple appointments throughout the year for lab work. Today, lab work once done in a physician’s office can be done at alternative locations, such as retail-based clinics, which are often less costly to both the health plan and the employee. Lab results can be added to the employee’s electronic medical record and shared with a primary care provider, allowing both the individual and their care team to stay engaged with always up-to-date information and frequent touchpoints beyond their in-person interactions.

Given how the consumption of care is evolving, employers must determine how they will increase the availability of options for their employees. Care management programs are poised to recommend care when appropriate, whether it’s for lab work or even to an Employee Assistance Program. Having healthcare support available on-demand, when you want it, where you want it, is now an expectation, not just a value-added service. By using digital tools to facilitate engagement, a care management nurse or specialist can have interaction with an individual wherever and whenever they need it.

Advancing health equity

When considering how to improve outcomes, it is important to keep in mind that not everyone has the same access to care or choices that help them achieve optimum health. This can depend on where they live, their socioeconomic background, gender, ethnicity and many other factors.

Much of care management is coordination, asking questions and providing education. Care management programs can help address disparities by addressing social determinants of health, reducing barriers to care, offering caregiver support, and connecting people to resources in their community that can help them live healthier lives. These resources can even include mental health services, an area we know disparities exist.

Establishing a relationship with a care management nurse, care specialist or pharmacist creates an open line of communication. While we know that many – particularly those in minority communities – often face barriers such as a lack of transportation, trouble paying for medication or not understanding the progression of a disease, these are all problems with solutions. Care management programs can be an important tool in advancing health equity, so that we can ensure that everyone has the opportunity to be as healthy as possible.

Making a rare disease not so rare

Having a rare disease can mean that your doctor has only seen your condition once or twice in a lifetime. But a nurse specialized in rare disease care management routinely interacts with individuals who have the same condition. Specialized training means that the nurse or specialist knows what the patient is experiencing. Having a connection to someone who knows the intricacies of side effects, medication details and what to expect can be very meaningful, and potentially change the trajectory by which people with rare conditions use healthcare.

By utilizing care management programs, employers can ensure that their employees with chronic conditions have an additional layer of support. Although care management only applies to a small subset of an employee population, the value and improvements seen can be significant. It’s just one way that employer health plans can facilitate behavior change that can lead to better health outcomes for the people they serve and improve the bottom line at the same time.

As President, Omnicare, Ahmed is responsible for leading our long-term care business, executing against our business strategy and goals in service, retention, growth and culture. Ahmed previously served as the President and General Manager of PBM Care Management, overseeing operations, clinical excellence, product development, sales and account management for Caremark’s Care Management portfolio, including Accordant, Transform Diabetes Care and Health Advisor. Ahmed has held various leadership positions across a range of healthcare and technology organizations in strategy, operations and product management, including working at a health and life sciences consulting practice where he helped the firm's payers, providers and pharmaceutical clients adapt to the changing healthcare landscape. Ahmed holds a Bachelors of Engineering degree from Northwestern University and an MBA from Kellogg School of Management.

Erika Glenn is an award-winning sales and account management executive with a unique blend of expertise across care management, pharmacy manufacturing, IT strategy, and solution development. Erika is a passionate champion for the end-to-end client experience with an emphasis on relationship development, member experience and value-driven solutions. As the Vice President and GM of PBM Care Management for CVS Health, Erika oversees product development and strategy, operations, clinical integrity, and sales and account management for the care management portfolio, including population health and condition-specific solutions. Erika has been with CVS since 2014 and previously led IT strategy and delivery for Accordant and Novologix. Prior to joining CVS, Erika held leadership roles spanning IT, project management and revenue for a large health system. Erika holds a Bachelors of Interdisciplinary Studies with an emphasis on Public Administration and Political Science from Winston Salem State University.

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