SAN MATEO, Calif.--(BUSINESS WIRE)--Healthcare leaders at the federal, state, and healthcare organization levels are progressively shifting towards population health to address current health inequities. “A key source of today’s health inequities is social determinants of health (SDOH), such as income, race, education, and social support,” stated Dr. Douglas G. Cave, President of CCGroup.
“With the progressive shift to population management, value-based payment models from Medicaid and Medicare are increasingly focused on SDOH to improve population health outcomes. Therefore, health plans and health systems want to understand a covered population’s SDOH characteristics, and then devote the necessary resources and activities to improve health.”
With respect to SDOH, health plans are focused on three main areas of development and program implementation: predictive modeling based on SDOH; patient risk-stratification based on SDOH; and targeting patients with emerging health risk. “CCGroup is actively involved with our health plans and health systems in each of these areas,” continued Dr. Cave.
One area of focus is the use of models that predict an individual’s need for healthcare based on available SDOH factors. This is because new health plan enrollees often have no prior healthcare claims experience, but new enrollees may have available SDOH information. Dr. Cave defined, “Some value-based payment models require SDOH information to be utilized to understand various at-risk groups’ immediate need for care.” The SDOH information is supplemented with claims experience as that information becomes available.
“CCGroup MediScreen™ is our well-established high-cost, high-risk patient predictive model. This model is based on an individual’s prior-year claim and encounter experience,” defined John Calvin, Vice President of Development. “With the recognized need to integrate SDOH, our CCGroup MediScreen™ model now predicts the need for care based solely on available SDOH information.” He continued, “These SDOH include age, gender, race, disability status, marital status, education level, income, and other SDOH factors. CCGroup MediScreen™ continues to use both SDOH and claims experience to better understand a covered population’s need for care.”
The second area of focus is to risk stratify a covered population based on SDOH factors. “CCGroup PrevalenceView™ allows the user to examine the healthcare claims experience of various SDOH sub-populations. This analysis allows health plans and other entities to better understand sub-population healthcare needs, and then target resources and activities to improve health,” stated Dr. Cave.
For instance, CCGroup PrevalenceView™ allows you to identify and assess the needs of sub-populations near the end of life, without stable housing, by race/ethnicity, by income level, and by social inclusion.
Dr. Cave defined, “CCGroup PrevalenceView™ often shows that members near the end of life have a significantly higher prevalence rate of chronic obstructive pulmonary disease (COPD), diabetes with multiple complications (specifically renal and circulatory), and congestive heart failure. Also, children with diabetes have a higher prevalence of major depression, other endocrine disorders, and urinary tract infections. This sub-population is often hospitalized four-times as often as other children. Understanding this information, health plans and health systems can devote the necessary activities and resources to improve health and reduce patient flare-ups resulting in hospital admissions.”
The final area of focus is to identify individuals with ‘emerging-health-risk.’ CCGroup PatientView™ allows health plans and other entities to identify this sub-population based on each individual’s Care Need Index (CNI). Dr. Cave stated, “The CNI for a member identifies and prioritizes her/his rank for being high-risk, high-cost, and the ability to impact current healthcare delivery.”
An individual’s CNI score is comprised of several components, including each member’s predictive risk score, current gaps-in-care for treatment, chronic medical conditions, recent emergency room and hospital admission utilization, and clinical lab results. A member’s CNI ranges from 0 (very healthy) to 5.00 (in need of immediate medical attention). “For emerging-health-risk, a health plan needs to pay attention to a member’s CNI score increasing on average 15% or more over the past three measurement intervals. These members need the most immediate attention,” mentioned Dr. Cave.
About Cave Consulting Group (CCGroup)
Cave Consulting Group, Inc. is a software and consulting firm located in San Mateo, California. The company is focused on improving the efficiency (cost-of-care) and effectiveness (quality-of-care) of the healthcare delivery system. Senior management of CCGroup has assessed the performance of physicians and hospitals for over 28 years for health plans, HMOs, physician groups, health systems, TPAs, and employers.