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4 key steps to manage high-cost members

By Ryan Rubino, Sales Director at Arcadia
Medical Cost Containment Healthcare Analytics

Ryan Rubino, Sales Director at Arcadia, discusses how Arcadia can help you manage high-cost members.

Step 1: Know who they are

It’s important to define criteria for high-cost members and know where they are coming from. At Arcadia, we often define those high-cost members as people having over $200,000 of spend each year. But that criteria may be adjusted dynamically based on the specific needs of your analysis.

Step 2: Know what’s driving the cost

Identifying what’s driving the costs requires some definition and organization.

At Arcadia, we've established a framework to split out high-cost members across several categories, including:

  • high-cost maternity
  • high-cost admissions
  • high-cost drugs
  • high-cost rare conditions
  • high-cost common conditions
  • unclassified

When it comes to unclassified, you'd like that to be less than 5 to 10%, and have all other categories add up to 100%. Along with understanding these high-level categories of spend, you may also want to stratify by payer, or a region within your network. Seeing that some contracts might bear more risk than others, it’s important this categorization is aligned with actions taken to improve patient outcomes.

Step 3: Stratify for impactability

Arcadia’s suite of impact scores are designed to identify members that are most likely to have positive outcomes, if enrolled in a care management program.

For example, there could be certain cancer treatments where enrollment in a care management program won’t make a difference. But, there might be other members that have a combination of conditions and social factors that would be significantly helped by a care management program.

Arcadia has taken this one step further to build out a suite of machine learning driven impact stability scores. These are essentially risk scores that help identify who, if enrolled into a care management program, is most likely to have a positive outcome from this enrollment. These impact scores are designed with specific care management programs in mind, such as complex care management, behavioral health care management, SDoH care management, and others to maximize the effort of care management teams.

Step 4: Automate your actions

Arcadia supports several AI-driven workflow applications to help with every step of the care management process from patient identification, to enrollment, to task scheduling, to care plan curation, all the way through to disenrollment.

With care management programs, there’s a lot of repetitive, mundane time-consuming tasks. You want to make sure patients don't slip through the cracks with manually supported processes. With Arcadia, you can automate the care plan curation process. This is another area Arcadia has invested heavily to develop AI-based workflow tools to make this process more reliable and make these care management teams more efficient.

Summary of the 4 key steps

To sum things up, everything discussed is part of Arcadia’s out-of-the-box solution.

A key way that we help drive value to our customers is by accelerating time-to-value, including data integration, patient stratification, and AI driven workflow automation.

Our goal is to make your entire team, including analysts and care team managers, be able to work at the top of their license and drive maximum value to the organization.

Managing high-cost members is just one small piece of the pie, but limited resources can drive a significant impact when taking some of your costliest members into account.

Learn more about Arcadia’s healthcare analytics platform.

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