5 Ways Insurers Can Improve Value For Polychronic Members


RaeAnn Grossman

8 min read

Patients living with three or more chronic conditions are among the most challenging and most expensive to treat. The pandemic disrupted care for chronic disease patients, whether due to limitations around in-person appointments or patients’ desire to avoid potential exposure to COVID-19. Now, with the population of polychronic disease members increasing and care delays affecting select populations more than others, experts expect an uptick in demand for care and increased potential for waste and abuse.

Even before the pandemic, 71% of healthcare spending went toward treating people with multiple chronic conditions, and experts anticipated a significant rise in the global burden of chronic disease. But COVID-19 ramped up risk for chronic disease and made it harder for physicians and health plans to provide the right care and quality oversight. Approximately 10% of people who acquired the virus were at risk for long COVID, with symptoms that ranged from extreme and persistent fatigue to chest pain, difficulty breathing and cognitive challenges. The risk of acquiring long COVID is higher for patients with preexisting conditions, such as diabetes, pulmonary disease, rheumatoid issues, and heart disease. With symptoms of long COVID continually evolving, experts do not yet have a good understanding of how best to manage these symptoms or whether it is possible to reverse the effects of this disease.

Health plans must reimagine and redesign care management for polychronic patients as the volume of members with these conditions rises and costs continue to climb. Below are five key considerations for health plan leaders.

1. Focus on health literacy. Just 12% of Americans are “proficiently health literate,” according to a 2022 Milliken Institute study. Health plans need to rethink not only how communications are delivered — for instance, ensuring that information can be accessed via the technologies members access most, such as their smartphones — but also the style of communication. Information should be crafted in multiple languages and with an understanding of how to engage individuals most effectively by culture. Just as cultural competence improves healthcare organizations' ability to provide care, it also strengthens member engagement and understanding of their health conditions. Health plans should strive to write communications at a basic level so members with polychronic conditions understand what their diagnosis means, what is involved in their plan of treatment and how to access a physician or nurse quickly when they need help. They should also continually evaluate the modes of communication to ensure they are using the most effective tool for each population.

2. Invest in a personalized, omni-channel approach to member engagement. Medicare Advantage plans are increasingly undertaking high-touch welcome opportunities, pairing members with a health plan representative who can help ensure that members understand their benefits. Some go so far as to schedule a member’s first appointment with their primary care physician under the plan. Some look for opportunities to connect members with polychronic conditions with health services in the home, such as visits from nurses, medication delivery, and meal delivery for members diagnosed with end-stage renal disease who are on dialysis. Like providers, health plans are also exploring the impact of digital engagement. At Ochsner Health, which also operates its own health plan, a pilot program that combines digital medicine with remote patient monitoring enabled half of patients with high blood pressure and nearly 60% of patients with Type 2 diabetes to reach their goals for control of their conditions within a few months. Efforts such as these strengthen treatment plan adherence and help connect members with the right care when data indicate intervention is needed.

3. Eliminate obstacles to obtaining a complete clinical picture of members with polychronic disease. Data leakage is another one of the challenges health plans face in helping patients with polychronic disease manage their conditions. This occurs when plans do not have a historical clinical view of a member upon enrollment. The health plan typically will know details such as where the member lives or their preferred benefit design but might not have access to the member’s current plan of treatment or medication history. Even as Medicare and Medicaid regulations demand that health plans share data in a specific way with one another, there may be lags due to lack of timeliness in data delivery. One step health plans could take is ensuring the member has an appointment with a primary care physician during the first 90 days of enrollment. This helps establish a single contact for leading the member’s care pathways. The conversations that result could also give health plans a better basis for understanding the member’s whole-health needs and what motivates the member to maintain their health.

4. Work to close gaps in social determinants of health data. Information regarding the types of SDOH a member faces is key to understanding their ability to adhere to a care plan. These include not just traditional SDOH such as food insecurity, housing instability and lack of reliable access to transportation, but also indicators such as the number and types of pets a member might own — which could limit the member’s discretionary income in ways the health plan might not anticipate — and whether the member’s housing protects them from extreme heat or cold. Greater understanding of the impact of nontraditional SDOH on chronic care management has prompted some Medicare Advantage plans to include supplemental benefits for pet food and pet care supplies. Other plans have opted to offer free air conditioner units to members according to their health needs.

5. Be vigilant against fraud, waste, and abuse. The pandemic presented significant barriers for chronic disease diagnosis, treatment, and follow-up. Now, pent-up demand will mean a surge in claims — and higher potential for fraud, waste, and abuse from bad actors. For instance, a spike in laboratory claims may necessitate audits to ensure health plans are not being billed for a higher-than-necessary volume of tests for a particular member or inappropriate types of tests based on the member’s condition. As bad actors become more creative, enriching claims systems with edits that prompt a higher level of review when suspicious activity is detected could prevent unnecessary expense. Another way to protect value is to audit instances of duplicative or inappropriate care across geographies and use the data to pinpoint “hotspots” for waste and abuse. With this information in hand, health plans can more effectively stop fraud in its tracks, preventing unnecessary care and risk exposure for members. By proactively setting strategies to improve polychronic condition management for vulnerable populations, health plans can assist in the delivery of more effective and more tailored care to their members that need it most. This will ultimately help them improve both clinical and financial outcomes, contributing to better quality scores and significantly increasing the plan’s sustainability in the long term. The industry must make healthcare simpler as patients’ needs and conditions get more complex.

To learn more contact Matthew Weinstock, Senior Editor, Health and Life Sciences.

  • RaeAnn Grossman