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Viewpoints Blog

Through Member collaboration, MCRA helps drive performance improvements, deliver exceptional service, transform care, and champion the health and wellbeing of the communities we collectively serve.

Better Caring for High-Cost Members

Originally posted by Esperta Health

It’s no secret that a small percentage of a health plan’s members account for a disproportionate amount of the plan’s medical costs. According to the National Alliance of Healthcare Purchaser Coalitions, the number of health plan members with claims of $3 million or more has doubled since 2016.

Those numbers represent all types of healthcare claims, but in the wound care space, we are seeing the same trend. Too often, health plans find themselves saddled with excessive payments for just a few members. It is an unsustainable model and requires a different way of thinking to better care for high-cost members.

Scale with money on one side and health care products on the other

Identify High-Cost Claims Drivers through Claims Data Analysis

Data is the key to understanding the problem and driving change. We need to see the full picture and understand why certain members and conditions monopolize our wound care dollars. This starts with a review of existing and historical claims data.

Beyond just looking at the data, the right questions must be asked:

  • Did the patient receive the right diagnosis?

  • Did they receive the proper care plan?

  • Were there barriers that prevented the patient from receiving or completing the treatment plan?

  • If a wound re-opened, what factors led to the recurrence?

  • Did the treatment plan incorporate the most effective resources?

Claims Data Analyses will answer those questions. We just need to dive into the numbers to chart a path forward.

Find New Ways to Solve Old Problems

This is not a new problem. Chronic wound patients continue to face the same barriers to care and healing as always. This necessitates a change. As an industry, we need to find new ways to address old problems.

That starts with place of service. We can remove some of the most prevalent barriers by delivering care in a patient’s home. This can ensure consistent quality and timing of care, which is critical when treating chronic wounds. Additionally, if we utilize wound-certified clinicians, we can raise the level of care our members receive, instead of relying on disparate processes and experiences.

Beyond better outcomes, a new path for treating chronic wounds will result in a lower spend for high-cost members. Esperta Health has found success with this method and is solving old problems by innovating the way chronic wounds are treated.

Support Long-Term Health

Esperta Health's role is about more than just helping patients get better. They must support long-term health. That means putting programs in place that keep patients out of the more expensive settings and establish a culture of wellness.

From a chronic wound care perspective, we need to ensure patients receive education and support to keep their conditions in check. Many hospitals and health plans have invested in population health programs. We need to continue to invest in programs that make entire communities healthier, which ultimately will lower costs for health plans.

Saving money on chronic wound care will have a tangible impact on the healthcare system itself. We can deliver better outcomes while controlling costs if we put new programs in place to manage high-cost members. It only takes a little innovation and a new approach.



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