Historically, benefit design focused heavily on member acquisition and retention, a strategy that fared well for most plans, especially large national plans with money to burn. Now, with the impending regulatory changes, benefits need to be tied to improvement in health outcomes, take a population health approach and must actually be utilized by beneficiaries. This presents quite a few challenges for plans as they design their benefits for 2025.
For decades benefits have been the epitome of “keeping up with the jones’- table stakes.” This strategy has resulted in low utilization and resulted in little to no impact on health outcomes. Now that regulatory changes, shifts in risk adjustment models, and alterations in fee schedules are forcing health plans to be more narrowly focused. Plans can no longer provide benefits simply to attract and retain members.
Targeted benefits that deliver interventions to specific cohorts/populations of members are potentially a mandate. Health plans are required to report the utilization of benefits that contribute to maintaining and improving health, as well as, demonstrate clear ROIs. To provide these results health plans must understand and clearly address the unique needs of distinct member populations.
Why Are Targeted Interventions a Good Idea?
According to a recent AHA report, by 2030, the 65+ population in the US will double in size. Within this population of aging adults:
- 6 out of 10 older adults will be managing more than one chronic condition
- 1 in every 4 will be living with diabetes
- 90% of these adults would prefer to age at home
- Yet, less than 6% of homes are set up for safe aging
Health plans can no longer apply the same tactics to address the growing and evolving needs of older adults in our country. Targeted interventions, SSBCIs and outcomes-focused Care Management Programs are the solution for this issue. Here’s why:
One compelling reason for health plans to shift towards building targeted benefits lies in the inherent cost-effectiveness compared to the traditional method of applying sweeping benefits across an entire population.
Customizing benefits to meet the unique needs of distinct groups can result in a notable reduction in the overall cost of care. For instance, consider a health plan that caters to an aging demographic with a high prevalence of chronic conditions. By tailoring benefits to address the specific health challenges faced by this group, which may include food is medicine, telehealth or home modifications, health plans can witness a substantial decrease in the inappropriate utilization of benefits and integrate trackable ROI. This can result in the form of reduced hospital readmissions, better management of chronic illnesses, and overall a much more efficient allocation of benefits.
The inefficiencies of generic programs become evident when they fail to address the root causes of health issues faced by specific members. Sweeping benefits may offer a broad array of services, but they often lack the specificity required to comprehensively tackle the diverse health concerns of members.
Greater return on investment by focusing on populations that are known to be at risk for injurious falls
Another reason for health plans to prioritize targeted benefits lies in the potential for a greater return on investment, particularly when addressing populations known to be at risk for injurious falls. The statistics underscore the significance of this issue, revealing that 28% of older adults are expected to experience a fall this year. However, the staggering figure of $50 billion worth of falls being preventable through targeted services, such as clinically-led home modifications, emphasizes the opportunity for substantial cost savings.
Consider the case of older adults who are at an increased risk of falls, especially after discharge.
Alarmingly, 42% of them will experience a subsequent fall, and a striking four out of five of these falls are attributed to environmental hazards. This presents a clear opportunity for health plans to intervene with targeted benefits. For instance, implementing a home modification benefit for individuals who have recently experienced a fall at home enables the plan to address a member's specific need in real-time. Or a health plan could even look at populations with certain conditions or behaviors that often are linked to an increased risk of falling (even if a fall hasn’t occurred yet).
This can include:
- Chronic conditions
- Changes in vision
- Incontinence
- Taking certain medications
In both of these scenarios, the targeted benefit not only serves as a proactive measure to enhance the well-being of at-risk individuals but also translates into a tangible return on investment. The cost of implementing home modifications is nothing compared to the potential savings in healthcare expenditures associated with preventing falls and subsequent injuries or worse, hospitalizations.
If you’re interested in understanding the measurable impact of home modifications, please contact our team at hello@jukeboxhealth.com or call us at (212) 321-5113.
Increases in Quality of CareNCQA and CMS provide a clear roadmap for Quality and Outcomes. To provide a benefit that results in real ROI, improved outcomes & following the mandates that NCQA and CMS have laid out, plans need a higher level of alignment across multiple departments. These departments include:
- Product
- Quality
- Care Management
- Utilization Management
- Provider Network
- Value Based Care
- Medical Economics
When working together, these cross-functional groups can create targeted benefits that allow health plans to have a better understanding of what their members need.
The result? The right care at the right time in the right setting, improved health results, reduced costs and superior performance outcomes as CMS requires.
For example: Although the Falls Risk measure is part of the Health Outcomes Survey (HOS) and has a lower weighting in STAR ratings, plans that score poorly in this measure should be on high alert. When providers are asked about having falls risk discussions with their patients, we often hear that they are hesitant even to bring it up. Why? Because providers (and health plans) do not have a service or solution to the problem.
Now that CMS is putting an emphasis on benefits that improve quality and outcomes, this is the perfect time to give providers a solution to a national crisis. Falls are the #1 cause of death and injury in older adults. And 4 out of 5 falls for people over the age of 65 are due to home hazards.
Identifying the need and sending pamphlets on removing tripping hazards is not a quality program or a benefit, and CMS agrees.
How Can Health Plans Effectively Design and Implement More Tailored Benefits?
Hold your vendor partners accountable and collaborate with them on a higher, more strategic level.
Jukebox Health specializes in carrying out home safety benefits & fall risk prevention programs. While the concept of aging in place is top of mind, proactive home modification interventions are still underdeveloped and limited. To make matters worse, the majority of older adults seeking solutions are in reactive-mode needing immediate help (often post-fall). In fact, 62% of individuals who come through our door require help within a two-week timeframe. A situation most health plans would not be ready to face.
This data tells us two critical factors about how an intervention, like home modifications, is best designed and deployed:
Take a Targeted, Population Health Approach
Our focus is to support older adults as they carry out their wish to stay in their own homes and out of an institutional setting. However, there remains a need to guide individuals toward proactive measures. Notably, many individuals are not actively seeking proactive home modifications despite the clear value of modifying the home to improve safety and accessibility. Because of this, we work with plans to target members who have a pain point and need immediate help to prevent falls and life-threatening complications.
Prioritize and Match Solutions with Actionable Data and Integrated Technology
Presently, there's a growing demand for health tech that transcends merely identifying needs. Health technology needs to connect members with the services they need as they are identified, providing a seamless benefit experience rather than leaving them to navigate a complex system independently. Telling a member they have a problem and then giving them the link to where they can buy a grab bar is not only poor service, it will never improve health outcomes. This is what Jukebox Health has built out with our fast and effective solution-matching software, Othello.
To sum things up, data strongly shows the wide range of positive results health plans can expect from providing benefits that are tailored to specific populations. To do this, health plans need an effective system that identifies and understands these precise needs. Once identified, it’s crucial to efficiently match those members with impactful solutions that result in positive health outcomes.
If you’re interested in seeing how we can help your plan build a targeted home safety benefit, please don’t hesitate to reach out to our partnership team. Reach out at hello@jukeboxhealth.com or call us at (212) 321-5113.
