Q & A: How care management can help lower costs, improve outcomes

Chronic conditions are one of the most consistent challenges for payors and plan members. They affect six out of 10 adults and account for 90 percent of all health care spending in the United States. Forty percent of Americans have two or more chronic conditions, further complicating care management. 

Furthermore, 50% of medications taken for chronic conditions are not regularly adhered to, costing an estimated $290B annually.¹ There is a significant opportunity to improve outcomes through better compliance with overall management recommendations. Depending on the condition, these are likely to involve not only adherence to prescribed medications, but lifestyle changes, screenings, and testing and monitoring of specific factors such as blood glucose and blood pressure. For many members, psychological state and social determinants of health may also need to be addressed.

It’s a complex and important challenge for both members and payors, and CVS Health has committed resources in an effort to improve care management results and simplify the experience. Ahmed Hassan, Vice President and General Manager of PBM Care Management, drives strategy and development of our care management programs. We sat down with him to discuss how CVS Health can contribute to PBM clients and members in this critical area.

What led CVS Health to develop and provide more care management programs?

Care management is a critical element of our role as the manager of pharmacy spend for our clients. There’s an enormous opportunity and an urgent need to improve outcomes for people with chronic and rare conditions. In many cases, outcomes can be improved and vulnerability reduced with what seem like relatively simple measures—making it easier for people to stay adherent, helping people get the needed tests and screenings, supporting lifestyle changes, basically helping them avoid the adverse events that really drive up health care spending. In actuality of course, these “relatively simple” steps can turn out to be very complicated to accomplish.

Looking at the need and the opportunity as well as the challenge, we felt that with our increased resources and capabilities CVS Health can make a real and substantial contribution to both our clients and their members in the area of care management. We’re developing and implementing programs that integrate technology, our clinical expertise, and our proficiency in member engagement. These programs are designed to have an impact on outcomes while also reducing costs. In fact, we’re so confident in our programs, we can offer a guarantee of savings in some cases in terms of reduced overall costs.

How has CVS Health advanced the use of data in care management?

We utilize prescription claims, medical claims and lab results, demographic data, historical engagement and member feedback. With this holistic data view, we identify members in need of support and provide individualized outreach with one-on-one connections that motivate healthier member choices, improving health outcomes. It’s our ability to connect one-on-one with members that makes our programs so effective. Our analytics engine analyzes member data to help determine an appropriate level of support.

Our data-based, member-level view allows us to identify not only the best type of intervention for each individual, but also the right channel and time to deliver the message and achieve the greatest efficacy. We are constantly reviewing outcomes and optimizing the system for even better results.

What results demonstrate the value of one-on-one engagement?

Data is critical in identifying members for outreach. We’ve found one-on-one engagement to be a critical next step, especially for more complex care patients. It’s in the one-on-one interventions where our nurses and pharmacists can find out about the specific issues and obstacles an individual might be facing.

Every day, our CVS pharmacists and MinuteClinic nurse practitioners provide one-on-one counseling and guidance, but members can also access an added level of support through solutions like Transform Diabetes Care. In addition to in-person engagement, we reach members telephonically and through text and email, and we offer virtual visits.

Members at high risk or with a rare or complex condition receive high-touch interventions. With Health Advisor, for example, the highest-risk members receive personalized guidance and recommendations from pharmacists. When they visit the pharmacy, pharmacists are alerted to engage with members either in-person or via the phone to drive health outcomes through ongoing, proactive one-on-one consultation. The goal is to have meaningful conversations that explore a member’s entire situation—not only their treatment, but also individual challenges, cost concerns, and social determinants of health that can affect quality of life and outcomes. It’s in such conversations that we can uncover the issues and identify solutions that can help support an individual’s behavior change. Leveraging the expertise of a highly trusted clinician and the most frequent interation in health care achieves 75 percent engagement.² Overall, Health Advisor improves behavior changes up to 15 percent.³

Another example of one-on-one engagement is with AccordantCare. Members with rare or complex conditions who participate in AccordantCare are assigned a dedicated nurse. This nurse will be the member’s main contact. These nurses are organized in disease- and client-specific groups, where they become highly specialized and knowledgeable in specific diseases states. Through this grouping, our nurses also develop a deep understanding of both patient and health plan needs. The dedicated nurse engages with the patient as often as needed—this could be monthly, weekly, or even daily at times—and addresses whole-person care. The relationship can last for years, and the benefits are substantial. Our data indicate a significant reduction in hospitalizations for these patients, as well as over $2,000 per year in reduced costs.⁴

AccordantCare Results:

• ~98% engaged members have a better understanding of how to manage their conditions⁵
• 11% reduction in hospitalizations⁶
• $2,158/yr estimated savings per engaged member⁷

How can payors identify and implement the right care management solutions?

Payors look to care management to address their specific pain points: tough competition in the marketplace, skyrocketing diabetes costs, the increasing cost of specialty drugs, and so on. CVS Health care management solutions are configured to address each payor's specific challenges, priorities and desired results. Each configurable solution will pull the various levers--data, engagement and retail presence--in different ways, resulting in a care management program customized to the needs of each payor and member.

For example, members with diabetes can be alerted to the need for specific testing while they’re picking up their prescription in a CVS Pharmacy. In many places, they can even act on that alert on the very same visit in one of our MinuteClinic or CVS HealthHUB locations. Or if a client wants to integrate medical and pharmacy programs, especially for high-acuity populations, we can co-design an approach that utilizes our data and analytics capabilities, local retail footprint, and clinical programs and resources to simplify the member experience and support better continuity of care. Through our close work with them, our clients can supplement their care management efforts using the assets of our entire enterprise and making it easier for people to get the care that ultimately lowers health care costs.

The source for data in this document is CVS Health Enterprise Analytics, unless otherwise noted. 
All programs may not be available in all states or for all lines of business.
Adherence results may vary based upon a variety of factors such as plan design, demographics and programs adopted by the plan. Client-specific modeling available upon request.
Savings will vary based upon a variety of factors including things such as plan design, demographics and programs implemented by the plan.
CVS Health uses and shares data as allowed by applicable law, and by our agreements and our information firewall.
CVS Health has extensive policies and procedures in place to ensure the appropriate handling of data. Employees with access to data are trained regarding the appropriate way to handle that data, which may include member PHI.
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