Change Behaviors

Relentless Health Value: Episode 462 with Converging Health’s…

Today, Dr. Scott Conard discusses the evolution of his life’s work, focusing on his current collaboration with Mike Adams from 7-Eleven to support their plan members. Their efforts revolve around a few striking yet common insights that many plan sponsors will recognize in their own data. One key finding: roughly 70% of individuals who exceed a plan’s high-cost threshold in any given year were previously high-risk but low-cost. These individuals don’t appear out of nowhere—they were identifiable in prior years. The challenge is to identify them early and provide the right interventions to prevent them from transitioning into the high-risk, high-cost category. Effectively managing a population requires proactive identification of high-risk, low-cost members before they escalate into high-cost care. To achieve this, Dr. Conard follows a best-practice, stepwise approach, which we’ll outline below. While we cover each step in the discussion, some are explored in greater depth than others. Best-Practice Approach to Managing Population Health 1. Get the Data – The Whole-Person Risk Score Rather than categorizing members into isolated disease groups, the goal is to assess risk at a whole-person level. Patients aren’t just a collection of separate conditions—they’re complex human beings whose health factors interact. Dr. Conard often uses a car analogy: If a car’s tires wear out, you simply replace them. But humans don’t work that way. A patient may need surgery but be unable to proceed because their cardiovascular markers are too high. Yet, they can’t take the necessary medication due to contraindications with existing kidney or liver conditions. This fragmentation in care often leads to patients being bounced between specialists who don’t communicate effectively. A real-world example comes from Miriam Paramore, who shares a harrowing story about her father’s end-of-life care—an illustration of why whole-person risk scoring is critical. 2. Provide Access to Advanced Primary Care Teams Members need access to high-functioning primary care teams that are empowered to make informed referrals to top-tier specialists. These teams should ensure care is high-quality, appropriate, and optimized for each patient. 3. Align Benefit Design with Optimal Care Pathways Plan sponsors must structure benefits to support the care members need. If benefit design creates barriers—like high co-pays for essential services—members may forgo necessary care, leading to worse outcomes and higher costs in the long run. Dr. Mark Fendrick once compared benefit design and optimized medical care to peanut butter and jelly—they must go together. For example, if a doctor tells a diabetic patient to get regular foot exams to prevent amputations, but the patient can’t afford the co-pay, the system fails. The patient suffers, the doctor’s quality scores take a hit, and the plan sponsor ultimately pays for costly, avoidable complications. Step 3 ensures benefit design supports, rather than hinders, effective care. 4. Engage Members with Navigation Tools Members need guidance to navigate the healthcare system effectively. Tools like My Personal Health Assistant play a crucial role in engaging unengaged patients and ensuring they follow optimal care pathways. These tools complement advanced primary care efforts, helping members stay on track and receive the right care at the right time. By following this structured approach, plan sponsors can proactively manage population health, reduce costs, and improve outcomes—transforming their approach from reactive to strategic.

Relentless Health Value: Episode 462 with Converging Health’s… Read More »

The Hidden Cost of Overutilization and Lack of Primary Care: A Call to Action for CFOs and HR Directors

Employer Healthcare Solutions / Converging Health Website

As leaders responsible for balancing the financial health of your organizations with the well-being of your employees, you face a complex challenge: managing escalating health insurance costs without compromising the quality of care. Two often-overlooked factors significantly driving these costs are the overutilization of medical services and a lack of primary care engagement among employees. Overutilization of Medical Services: Paying More for Less Overutilization occurs when medical services are provided with a higher volume or cost than is appropriate. This includes unnecessary tests, redundant procedures, and avoidable emergency room visits. While these services may seem beneficial on the surface, they often do not contribute to better health outcomes and can, in fact, expose patients to unnecessary risks. For example, an employee with a minor headache might receive an expensive MRI scan when rest and over-the-counter medication would suffice. Such instances not only inflate individual claims but also contribute to higher premiums for the entire organization. Overutilization can account for up to 30% of healthcare spending, a staggering figure that directly impacts your bottom line. The Role of Primary Care: The First Line of Defense Primary care physicians (PCPs) serve as the gatekeepers of health, providing preventive services, managing chronic conditions, and coordinating specialist care. However, a significant number of employees lack a strong relationship with a PCP. This absence leads to fragmented care, delayed diagnoses, and increased reliance on specialist and emergency services—all of which are more costly and less efficient. Without primary care guidance, employees are more likely to self-refer to specialists for issues that could be managed by a PCP at a lower cost. They may also overlook preventive measures, resulting in advanced-stage diagnoses that require expensive interventions. The lack of primary care exacerbates overutilization by funneling employees into high-cost healthcare settings unnecessarily. Connecting the Dots: How These Issues Compound Costs The interplay between overutilization and lack of primary care creates a feedback loop that drives up healthcare expenses. Employees without primary care guidance are more susceptible to overutilization, and overutilization further discourages the establishment of primary care relationships due to the complexity and frustration it can cause. This cycle leads to: A Strategic Approach: Investing in Primary Care to Reduce Overutilization To address these challenges, consider implementing strategies that encourage primary care engagement and reduce unnecessary medical services: 1. Promote Primary Care Relationships: 2. Educate Employees: 3. Implement Value-Based Insurance Design: 4. Partner with Providers: Conclusion: A Call to Action As CFOs and HR directors, you have the opportunity to transform these challenges into strategic advantages. By fostering a culture that values primary care and actively combats overutilization, you can reduce healthcare spending while enhancing the well-being of your employees. Investing in primary care is not just a cost-saving measure; it’s a commitment to the long-term health of your workforce. It leads to better health outcomes, increased productivity, and a more sustainable financial model for your organization. It’s time to take a proactive stance. Let’s work together to build a healthcare ecosystem that delivers value, promotes health, and ensures that every dollar spent contributes meaningfully to the well-being of our employees and the vitality of our organizations. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

The Hidden Cost of Overutilization and Lack of Primary Care: A Call to Action for CFOs and HR Directors Read More »

Revolutionizing Population Health Risk Reduction: A Shift from Historical Costs to Root Causes

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

Written by Scott Conard, MD When it comes to population health risk reduction, the conversation is evolving. Historically, in the U.S., managing health costs has often been approached from an actuarial perspective—calculating insurance premiums based on past expenses and statistical projections. While this method has served its purpose, it focuses on trailing indicators like price per procedure and frequency of use, leaving the underlying drivers of healthcare costs largely unaddressed. But now, a shift is happening. We’re moving beyond simply accounting for costs to asking critical questions: What’s causing these costs to rise? What are the leading indicators that drive health risks and, ultimately, healthcare utilization? Moving Beyond Actuarial Science Traditional actuarial science calculates costs by factoring in variables like age, geographic location, medical diagnoses, and prescription usage. Insurers then project future costs based on past patterns, layering in adjustments for population demographics. While precise in its methodology, this approach is inherently backward-looking, focusing on how much was spent last year rather than proactively addressing what might reduce future spending. At its core, healthcare costs boil down to two key factors: price and use. But focusing solely on these metrics ignores a fundamental truth: the largest driver of healthcare cost is the risk of illness within a population. A high-risk population will inevitably lead to higher utilization and costs, while a low-risk population is significantly less expensive over time. Identifying and Addressing Health Risks To reduce health risks, we must first identify them. The answer lies in analyzing the population’s disease burden and the lifestyle factors driving it. Experience has shown that approximately 30% of a company’s population will eventually account for the majority of high-cost claims. More importantly, about 70% of those costly claims stem from conditions that could have been mitigated through early intervention and risk reduction. Lifestyle and Emotional Health: The First Line of DefenseMany of the conditions driving healthcare costs are preventable. Addressing lifestyle factors and emotional well-being plays a pivotal role in risk reduction. Strategies include: Navigating Healthcare Smarter The second pillar of health risk reduction involves empowering individuals to make smarter healthcare choices. This includes: High-Quality Care = Lower Costs A critical insight emerges when we focus on proactive health management: the highest-quality care is often the least expensive care. By identifying and addressing risks early, we not only improve health outcomes but also manage costs more effectively. Predictive analytics allow us to foresee who may require expensive treatments like surgery or dialysis, enabling timely interventions that are both effective and cost-efficient. The Future of Population Health This shift in focus—from trailing indicators like price and use to leading indicators like disease risk—represents a fundamental transformation in how we approach population health. By addressing the root causes of illness, promoting healthier lifestyles, and ensuring access to high-quality care, we can achieve significant reductions in healthcare costs while enhancing overall well-being. The path forward is clear: organizations must prioritize proactive health management strategies that address the underlying drivers of risk. By doing so, they can create healthier populations, reduce costs, and foster a more sustainable healthcare system. This isn’t just good for business—it’s essential for the future of healthcare. Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

Revolutionizing Population Health Risk Reduction: A Shift from Historical Costs to Root Causes Read More »

Health Risk Engagement Strategies: Driving Change Before It’s Too Late

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

For executives managing health plans, one of the biggest challenges is engaging individuals who are in the early stages of disease risk progression but feel perfectly fine. These individuals, often unaware of the looming consequences, present a significant opportunity—and a unique challenge—to healthcare strategies. Once someone becomes symptomatic, behavior change is much easier; they’re desperate to feel better. However, by then, it’s often too late to reverse the damage. Instead of cheaply and effectively addressing the issue, we’re left managing a chronic condition for the foreseeable future. The key question: How do we engage people early, before symptoms appear, and inspire them to take meaningful action? This is where cutting-edge health risk engagement strategies, driven by predictive data and real-time activation technology, become a game-changer. Our algorithms utilized by the MyPHA team is your solution to this problem. Shifting the Paradigm: From Retrospective Cost Analysis to Proactive Risk Engagement The status quo in healthcare analytics relies on retrospective cost-based reporting. Most organizations are equipped with tools that answer questions like: These data points are useful for understanding the past but do little to impact the future. They focus on individuals who are already in the high-cost, high-risk category—individuals whose health trajectory has already caused irreparable harm. What’s missing from this equation is predictive engagement—the ability to identify the individuals who are trending toward risk before they become symptomatic and to intervene effectively in real time. Consider this: 70% of today’s high-cost individuals won’t be the same people next year. If you’re only looking at historical data, you’re blind to the emerging risks within your population. Why Predictive Engagement Matters Let’s look at the CFO perspective:“I’ve already got reports. I know I have 384 diabetics and 264 people with hypertension. I have programs in place for them. Why do I need anything more?” Here’s why: Traditional reports don’t tell you who your next high-cost individuals will be, nor do they provide actionable insights about how to prevent them from becoming costly. They miss the nuances of health risk drivers—factors like comorbidities, social determinants of health, geographic influences, and behavioral patterns—that determine whether an individual can avoid a serious medical event. Predictive engagement goes beyond labels and costs. It examines the whole person—integrating data about: This holistic approach enables organizations to answer the most critical question: How can we prevent costly and emotionally taxing events before they occur? Engagement, Activation, and Support: The Pillars of Early Intervention Effective early intervention requires a three-pronged approach: For employers, early intervention is not just a health imperative; it’s a financial one. But this requires a shift from reacting to past costs to proactively managing future risks. By investing in predictive analytics and engagement technology, organizations can reduce costs while improving outcomes for individuals. Conclusion: The Future of Health Risk Management The old approach—focusing on retrospective cost and disease management—is no longer enough. Health risk engagement strategies must evolve to focus on real-time insights, whole-person care, and proactive prevention. The stakes are high, both for individual lives and corporate budgets. But with the right strategies, tools, and commitment, we can make a measurable difference—shifting the focus from managing disease to building health and resilience. As executives, the question isn’t, “Why should I care about your data?” It’s, “How can I afford not to?” By embracing proactive engagement, activation, and support, you can ensure your organization is leading the way in creating healthier, more productive populations. That’s a future worth investing in.

Health Risk Engagement Strategies: Driving Change Before It’s Too Late Read More »