By Joanne Shaffer, R.N., CCM, CCDS and Amin Serehali

The term “health risk” in health insurance is typically associated with the process underwriters use when setting premium rates. However, health risk is also a focus for health plans’ Information Management approach because it can be used to help set a company’s objectives in addressing chronic conditions not only in a wider health plan population context, but in individual situations as well.

For members, risk identification can help connect them to care management strategies that can help improve their chronic conditions, thus leading to improve quality of life or even saving lives.  For employers, risk identification that leads to proper care management can mean improving productivity, lowering absenteeism and reducing overall costs in the long run. 

The identification of health risk has come under scrutiny following a recent study that calls into question how a popular risk identification and prediction system unintentionally resulted in unequal determination of the need for health care interventions. While health plans have every incentive to predict potential adverse health outcomes, they will miss some and erroneously predict others. Models are not designed to discriminate, but they may have limitations that users of the information at the health plan need to understand and discuss before using the information they have.

Instead of relying on a single risk measure such as predicted future cost to determine health care interventions, Independent Health considers several data elements to define an individualized member’s health status and level of risk in order to align members to the right care management program.

Below is a list of some additional data elements that Independent Health uses to assess and determine member risk stratification levels:

  • Chronic conditions: Independent Health uses medical claims data to identify members with common chronic diseases. The presence of chronic disease indicates the need to manage the member’s condition through disease management, member education and self-management, care giver education, etc.
  • Presence of Mental Health condition: The presence of mental health conditions is used to determine the need for customized Case Management strategies according to a member’s challenges in order to aid members in their recovery.
  • Number of chronic conditions:  A high number of comorbidities indicates the need for higher level of coordination among the care team to manage the member’s health condition. Independent Health identifies members with multiple chronic conditions and assists them in obtaining access to care and navigating a complex healthcare system.
  • Number of unique dispensed medications: This also may indicate high number of chronic conditions and therefore a need for care management interventions such as care coordination, medication therapy management, medication adherence and member education.
  • Number of unique providers seen in the last 12 months: Members with a high number of unique providers are identified and, as indicated, Case Management will consider and prioritize members whose care requires coordination from a relatively large number of providers in an attempt to engage the member and perhaps reduce potential fragmentation and duplication of services.
  • Number of inpatient stays in the last 24 months: High inpatient utilization usually signals increasing acuity of illness as well as potential issues or barriers within the healthcare delivery system.
  • Number of readmissions in the last 24 months: Repeat admissions indicate potential poor health management due to systematic issues, social determinant of health or other healthcare-related barriers that will continue to drive poor outcomes if not addressed, such as poor transition of care or social barriers.
  • Number of Emergency Department visits in the last 24 months: A high number of ER visits may indicate potential access to care issues, psycho-social needs, or other healthcare-related barriers.
  • Gaps in recommended care: Independent Health measures gaps in care for preventive measures, as well as acute, chronic and behavioral health measures. Gaps in care (such as absence of childhood immunization) may indicate a need for health education, or signal potential social issues, health access barriers or other health related needs.
  • Change in cost trajectory: A change in cost trajectory may indicate a recent change in health status and allows Independent Health to intervene quickly before the member’s health further deteriorates.
  • Healthcare services non-users:  This data element identifies members that are not utilizing healthcare services. Independent Health uses the data to assess under-utilization patterns that may result from lack of access to care, lack of education or other social determinants of health thus allowing the plan to assist in aligning members with appropriate needed resources.
  • Vulnerability index: The Vulnerability index was developed by Independent Health using Census data to identify underserved geographic areas. Nine social indicators, including access to care, food security, transportation, employment, and education are used to develop an index ranging from 0 to 9. A census tract with score of 9 indicates the highest level of social and health needs and therefore may infer a higher level of resources needed to drive better health outcomes.

Just as we use a comprehensive approach to identify risk and help members who need intervention, we use a comprehensive approach to provide the services they need, whether it’s from our own care managers, coordination with physicians and other health care providers, or linkages to community resources. 

This cross-functional and cross-departmental discipline to help our members is evident in our performance as a top health plan in terms of quality, service and care coordination, and our employer clients can rest assured all of their employees and covered family members have the same opportunity to get the right care and services they need.

The authors

  Joanne Shaffer, R.N., CCM, CCDS, is Director of Case & Disease Management for Independent Health. Amin Serehali is Vice President of Clinical & Business Informatics for Independent Health