Insight to Action

Want to Impact Health and Costs? Focus on Driving Behavioral Change

6 December 2016

Many self-funded employee health plan sponsors are facing double-digit cost increases, and healthcare employers are no exception. Southcoast Health, a not-for-profit health services system serving 33 communities in Massachusetts and Rhode Island, decided to do something to change this unsustainable trend. Their story is instructive.

Realizing that the medical management offered by its insurance carrier was having little to no effect, and that employee contributions were rising every year, Southcoast knew that a radical transformation was needed. They worked with Cammack Health, now part of Aon Risk Solutions, to develop and implement a multi-dimensional strategy focused on changing member behavior and leveraging their own healthcare services through domestic steerage.

Southcoast instituted a three-tiered system of financial incentives to encourage health plan members to utilize the health system’s own inpatient, outpatient and lab services, as well as physicians. This is significant, as true domestic steerage begins with providers. Members paid least when using Southcoast’s own facilities and providers; they paid standard market rates for using local, in-network services and providers; and paid the highest costs for going out-of-network.

They went a step further, introducing independent third-party precertification and utilization management services. Often when using carrier based utilization management services, the carrier is prohibited from steering members to certain providers or facilities because of contractual terms with their network providers. By using an independent organization, the UM nurses were able to educate members on the financial consequences of their choices, direct them to high quality domestic providers, thereby increasing the rate at which members choose domestic services.

Southcoast also took steps to encourage member engagement in their own health. They launched a Personal Health Management (PHM) program focused on modifying high-risk behaviors, managing chronic and acute conditions, and educating members to make healthy choices. The Personal Health Nurses are part of the same independent medical management organization, are locally based, participate in the Health Plan governing body and integrate with Southcoast’s own Care Management team.

A key part of the program is this team of Personal Health Nurses (PHNs) who leverage predictive analytics to identify and reach out to high-risk members whose complex conditions drove spending five to eight times the plan average. PHNs begin working with members early in the process of care, helping identify issues that could impact optimal care, outcomes and cost.

The results were significant: Southcoast has decreased utilization costs, saving more than $17.2 million annually compared to national trends—while keeping employee contributions flat. Most importantly, members and their families are enjoying improved health.

To learn the whole story, read our white paper, “Achieving the Triple Aim: How One Health System Reduced Costs and Improved Member Health.”