Teladoc aims to reduce healthcare costs by identifying and managing complex cases. It’s generally accepted that 5% of the population drives 50% of healthcare costs, but pinpointing these cases can be tricky due to time constraints, medical information fragmentation, and dissemination of evidence-based information.
According to the report, health plans should work with partners to identify complex and costly cases, ensuring they’re on the best possible path and making adjustments as needed. They can do this even before these patients appear on the health plan’s radar.
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An integrated program that matches cases with the right expertise and resources can help health plans improve outcomes and care quality while reducing costs and strengthening relationships. This approach is essential for effective case management.
The Teladoc Health Plan Claims Analysis Study found that in 87% of cases reviewed, patients adhered to expert recommendations, resulting in a per-case savings of approximately $39,000. When patients didn’t follow recommendations, costs were five times greater.
Identifying complex cases can be done through claims data and clinical data, but success increases with well-trained case managers and the right clinical resources to spot trends. They look for signs of complex cases, including cost escalations, multiple ED visits, and the use of multiple drugs in the same therapeutic class.
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Certain conditions, such as irritable bowel syndrome and diabetes, raise the risk for patients to land in the complex care category. The researchers found that finding the right cases at the right time for an expert medical review can lead to lower overall utilization of healthcare services by reducing unnecessary tests and procedures.
A Complex Case Consult can reduce utilization of acute-care and high-cost settings by between 25% and 34%. Health plans realized 97% of their savings attributed to this reduction within the first six months of the expert case review.
Augmenting case management with an expert medical review program for complex cases can expand the treating team’s capabilities, ensuring every member can make well-informed medical decisions to receive the best possible care. Many patients with complex cases are taking expensive medications, and spending on specialty drugs increased by $54 billion over the past five years.
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An expert medical review for a member with a complex case may result in a recommendation for lower-cost medications with similar efficacies, improving the outcome for the member and resulting in significant savings for the health plan.
By identifying and managing complex cases, health plans can reduce unnecessary and ineffective care, strengthen payer-provider integration, and improve outcomes for their members. This approach can lead to significant cost savings and better care quality, making it a valuable strategy for health plans to consider. Find out how health plans are reducing costs and improving outcomes for their complex cases by downloading Teladoc’s Executive Summary: Health Plan Claims Analysis Study.
