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Evaluating Health Plan Medical Management Program Savings

Our quick take

Health plan CMOs are held accountable for reporting medical management (e.g., case, utilization and disease management) program savings to internal leadership, employer groups, and state regulators. However, definitions of medical management programs and savings methodologies often differ across plans. These challenges make it difficult for CMOs to benchmark their program performance.

How are plan-driven case management programs currently performing?

Advisory Board asked plans to self-report their case management program performance. Savings were defined as gross savings (excludes investment or operational costs) and reported on either a yearly or per-member-per-month level.

Six health plans and nearly 8M members are represented from the Northeast, Midwest, and West regions of the country. Commercial, Medicare, and Medicaid lines of business are included, and the average membership size is 1.3M. Included below are the preliminary results.

CMO commentary

CM engagement is someone that was targeted, invited, accepted the invitation, and worked with a case manager on their gap closures.

We look at the entire population’s utilization pre- and post- engagement in CM, and then calculate cost savings.

Advisory Board analysis of self-reported plan program savings

Advisory Board analysis of self-reported plan program savings

Programs included:
Complex case management,
care coordination, ED and readmissions avoidance

Average plan PMPM spend
on CM (Sherlock data)

Average plan PMPM net
on CM

Insights on case management savings methodologies

Three ways plans calculate CM savings:

  1. Compare cost of enrollee versus cost of non-enrollee in a given time period (Plan A, B, and C)
  2. Compare cost of enrollee pre- and post-engagement (Plan C)
  3. Savings based on reduction in specific outcomes (e.g., ED visits, readmissions) compared to average cost of outcome (Plan D and E)

Download the full report to learn more about:

  • Demographics of plans included (e.g., membership size, lines of business)
  • Program descriptions (e.g., case, disease, and utilization management, pharmacy)
  • Program savings methodologies (e.g., how plans calculate savings per program)

Want to submit your plan’s data? Email Jasmine DeSilva at desilvaj@advisory.com.

Download the program savings template.

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