Clinical Care Management in Action

By Justin Tran,
EVP Product,

Employee health benefits are a significant spend for companies. According to the Kaiser Family Foundation (KFF) Employer Benefits Survey[1], employer contributions for family coverage averaged $16,253 in 2021. Average annual worker contributions for single coverage cost $1,299, with family coverage averaging $5,969 annually. With healthcare costs continuing to rise, CFOs and CHROs are increasingly being asked to not only manage employee healthcare costs but also continue to support and prioritize their populations’ various health and well-being needs.

Clinical Care Management (CCM) proves a viable solution because it lessens unnecessary utilization and enhances the alignment of treatment intensity with a diagnosis. More specifically, an outcomes-driven CCM program offered by the benefits administrator allows employers to reduce healthcare spend while maintaining – or even improving – the quality of care provided.

This year, HealthComp, one of the nation’s leading independent third-party administrators (TPAs), conducted a study with actuarial firm, Wakely, that was recently verified and independently validated by  Validation Institute. The research centered on HealthComp’s CCM outcomes and concluded that employers who chose to opt into the program experienced30% lower overall utilization rates and 48% lower inpatient-allowed costs. Notably, HealthComp’s per employee per month costs were $82.47 lower than those in similar groups.

HealthComp’s CCM program encompasses a personalized, communication-driven care delivery approach that evaluates an individual’s overall health and uncovers any barriers to care they may face. HealthComp’s Care Managers use claims and member-submitted data to identify members who may benefit from CCM. The Care Managers reach out to members to explain the program and encourage enrollment, as these programs are opt-in rather than opt-out, providing a more accurate reflection of member participation. Care Managers help members manage their conditions by offering support, highlighting available resources members may not have been aware of in their benefits, and offering guidance so members can better adhere to their care plans.

The above numbers show the impact of Care Management from an actuarial standpoint, while the case studies shared below show how these programs benefit the individuals served.

Case Study 1: An At-Home Care Solution Increased Positive Outcomes and Lowered Costs

A member managing Crohn’s disease was regularly missing infusion treatments when their spouse was unable to transport them due to work commitments. These missed appointments naturally resulted in the member experiencing increased symptoms.

A Case Manager from HealthComp’s Clinical Care Management program researched the patient’s available rideshare and community transportation resources and found that options were limited. In constant communication with the member, the Case Manager uncovered the member was interested in at-home treatment. In the end, HealthComp found a physician- and patient-approved home health provider and secured a Preferred Provider Organization-level home health discount. The patient never missed another treatment, and their symptoms and lab work improved. They have since been discharged from the Clinical Care Management program, though their Case Manager is in direct contact with the member as a support system.

By switching their infusion venue, HealthComp helped the member increase treatment compliance, which resulted in good disease control. HealthComp also helped them avoid hospital admissions, resulting in nearly $18,000 in employer savings. Additionally, in-home infusion versus outpatient infusion at a clinic saved the employer nearly $130,000 annually.

Case Study #2: The Right Resources Drove a Successful Mental Health Intervention

A health plan member’s child with a history of aggressive behavior had been admitted to the emergency room several times and needed mental health treatment. A Case Manager from HealthComp’s Clinical Care Management program collaborated with the parents and care professionals to help the child avoid unplanned—and potentially disruptive— emergency room visits and inpatient admissions.

HealthComp encouraged the child’s family to seek a full psychological evaluation. The parents, after willingly learning more, agreed this option was worth pursuing. The evaluation revealed the child had high-functioning autism spectrum disorder. Different school and at-home interventions, as well as medication adjustments, were implemented based on this diagnosis. In addition, HealthComp located a therapeutic boarding school that could greatly benefit this child and even offered funding and grants. As a result, this child’s behavior improved over time, and they avoided further emergency room visits.

Personalized Care

Benefits administrators have an essential role to play in not only cost containment but also in closing gaps in care when a patient has needs that cannot be met in a physician’s office. Traditionally, the industry sees Clinical Care Management programs as a way to simply drive down the cost of care and utilization. However, as exemplified above, Clinical Care Management programs deliver personalized approaches to people who need them most, thus increasing member engagement while empowering patients to recognize their needs and options, making a quantifiable positive impact on their health outcomes.

[1]Employer Health Benefits 2021 Annual Survey.

Read HealthComp Savings Validation Report HERE.