Medicare Advantage plans improve member outcomes compared to traditional Medicare. One reason for this positive impact is their ability to connect high-risk members with resources and programs to limit costs and utilization. To accomplish this, plans must find ways to proactively identify those at highest risk and intervene at the right time. Plans also have an untapped opportunity to identify and support rising-risk Medicare Advantage members or those with behavioral health needs before they become high-risk.

To identify high-risk members, plans often rely on retrospective claims reviews based on cost and emergency department utilization. While this approach can be effective, it lets members escalate to the highest risk level before being connected to programs or enrolled in care management. At the same time, members with behavioral health needs that can contribute to or prolong physical health conditions often aren’t identified in claims reviews.

Plans have a significant opportunity to invest in proactive identification to assist their moderate, rising-risk members and prevent them from reaching that high-cost, high-risk threshold altogether. Thoughtful applications of technology can enable plans to identify and support their Medicare Advantage members upstream and address their conditions before symptoms worsen.

Identifying Behavioral Health Needs Is Key

Unaddressed comorbid behavioral health conditions are a main driver of high medical spend. According to a Milliman study, 57% of total healthcare costs come from individuals with a behavioral health condition. The vast majority of these costs are related to physical health. Unaddressed behavioral health needs lead to physical health deterioration and significantly higher utilization.

Behavioral health conditions are prominent among the Medicare Advantage population. Another study published on the JAMA Network found that among over 56,000 Medicare Advantage members, 38.6% had at least one behavioral health condition, and 54% had a health-related social need (HRSN). 25.3% had both a behavioral health condition and HRSN in the last year.

Developing a standardized way to screen, identify, and support Medicare Advantage members with behavioral health needs, alongside managing physical health conditions, can help eliminate high medical costs and prevent rising-risk members from becoming high-risk. According to the Health Care Advisory Board, one fifth of rising-risk members will become high-risk each year, which is why managing both high- and rising-risk members is critical for improving clinical outcomes and achieving financial sustainability.

Technology Enables Better Identification & Caseload Management

Increasing a care manager’s caseload to account for rising- and high-risk members is not always feasible. Care managers can contact a limited number of members in a single day, and hiring more staff to make up this shortfall is not always possible. Technology solutions such as NeuroFlow can fill these gaps in care management by delivering remote assessments and supported self-management solutions to much larger populations while increasing care manager efficiency.NeuroFlow provides the digital infrastructure health plans need to remotely assess and identify individuals who are at-risk and manage physical and behavioral health needs holistically. NeuroFlow delivers remote, tailored self-care resources to help members navigate grief, manage anxiety, or practice mindfulness. The digital experience is customizable and connected, incorporating the resources and programs in which health plans have already invested but may be underutilized.

Digital assessments and other in-app activities inform NeuroFlow’s proprietary severity score. If a member’s severity score worsens, for example, he may be assigned targeted depression content or he may be flagged for crisis support and triaged into a suicide prevention or other higher risk program. Care managers receive alerts when severity scores change significantly, helping them better understand which resources or programs a member may benefit from.

This feedback loop is critical to improving care manager efficiency and supporting members with rising risks before they reach crisis. For example, Prudential improved identification of behavioral health needs using NeuroFlow, finding that 19% of its physical disability claimants had previously unidentified mental wellness needs. This insight empowered case managers to prioritize outreach and provide holistic support to help claimants feel better and return to work.

With improved identification and prioritization, NeuroFlow is increasing care team satisfaction. In fact, care teams report 90% satisfaction with NeuroFlow’s solution, specifically calling out the way it helps them prioritize outreach and support members asynchronously using digital tools. 

The Future of Medicare Advantage

Waiting for claims reviews and providing manual outreach alone cannot support the growing need for behavioral health support among Medicare Advantage members. To support the whole health of members, managers need greater insight into both physical health and behavioral health needs. New technology solutions are helping care managers access these insights in a unified platform and proactively identify members in need, enabling plans to support larger Medicare Advantage populations and drive better outcomes.

Learn more about how NeuroFlow can support your Medicare Advantage members here.

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