Insight to Action

Want to Improve Population Management? Make Sure Your Health Plan is Aligned with Your Strategy

26 January 2017

Implementing a care management program designed to promote healthy (and cost-effective) member choices can make a real impact on healthcare utilization and costs. But is your self-funded plan optimized to support these efforts? If not, your care management strategy could fall short of its goals.

Cammack Health was privileged to work with Montefiore Health System of New York on a comprehensive program focused on moving employee health and cost trends in a positive direction. The program was truly an integrated initiative combining health education, care coordination, disease management, and provider engagement. But it didn’t stop there.

Together with Montefiore’s Human Resources leadership, we took a good, hard look at their self-funded health plan. We found that the plan was not competitive with the health system’s peers. Just as important, we found that the plan was not entirely aligned with their care management efforts. We worked closely with Montefiore to identify and address opportunities for improvement.

The prescription plan was a key area of focus. Working with Montefiore’s pharmacy leadership, we helped develop new clinical management rules—including step therapy, safety edits and prior authorization rules—designed to help promote clinically effective medication use, while optimizing efficiency.

We also recommended changes aimed at creating incentives for members to use less costly generic medications and to obtain them from the Montefiore pharmacy. Previously, members could fill their prescriptions for both branded and generic medications at the in-house pharmacy at no cost. We recommended introducing co-pays for branded medications obtained in-house and increased co-pays for all prescriptions filled outside Montefiore. Members can still fill generic prescriptions for free at the Montefiore pharmacy. In addition, initial supplies chronic condition medications are limited to 30
days, helping minimize waste in the event medications or dosages were to change.

Nutrition was another area of focus to address the high rates of obesity and diabetes among the members and their families. The revised plan now covers nutritional counseling for more conditions than is typically covered in employer plans.

Another important change was the implementation of precertification requirements designed to steer members to appropriate in-system resources. In addition to lowering employee out-of-pocket costs by keeping members in-system, this change provided an effective way to connect members requiring care with the Care Guidance program to proactively provide health management assistance.

With these changes, the health plan provided effective incentives for members to make choices that helped promote their own health and more efficient utilization of healthcare resources. Just as important, the optimized health plan was also competitive with those of other New York hospital employers—a crucial factor for attracting and retaining top talent.

If you haven’t already, maybe now is a good time to take a good look at your self-funded health plan in the context of your population management strategy. Make sure they are working in concert, rather than against each other.