What's Causing Your Health Plan Foundation to Crumble?

By: Nic Hayes

Unbeknownst to you there is a hole in your roof allowing water, leaves, and bugs into your home. You continue to hire exterminators, water damage restoration services, and others to preserve your home in an attempt to protect it from damage. Of course, you can’t see the hole in your roof, so at the time you think the best course of action is to handle the damage you see instead of determining the root cause of the problem, but when damage continues to happen in the same area, the light bulb goes off that you may dealing with a bigger, structural issue that if fixed could save you a considerable amount of money and time compared to the consequential repairs you were doing before…


When looking at a health plan and the costs associated with it, what is the hole allowing the majority of costs in? Most people associate high-cost claimants with tragedies, traumas, and specialty drugs. While these do account for a significant portion of the plan spend, it cannot be predicted and prepared for year after year. Instead, when looking at plan spend, an often ‘invisible’ group of high-cost claimants can be identified, and that ‘invisible’ group is plan members with 5+ simultaneous chronic conditions.


The hole in your health plan roof.

These conditions could range from medical conditions such as obesity, asthma, and joint pain to mental health conditions such as anxiety, depression, and PTSD to social determinants such as economic stability, education, and social and community context. When people are living with multiple of these conditions, it affects plan spend as well as their engagement and productivity at work.


From a plan standpoint, people living with 5+ simultaneous chronic conditions make up about 5% of adults on the plan, but they account for 20% of the total plan spend. What makes this population of plan members invisible is the fact that they are not seen on an annual basis. However, when you look at three-year spend, 50% of this group is in the top 10%, and 90% of this group is in the top 20%. Furthermore, to get a sense of how costly this population can be to the plan in a numbers sense, a plan with 250 members with 5+ chronic conditions can expect to spend $83 million over 10 years or $128million if absence costs are included.


Seeing how costly this population can be, it would be wise to determine the root cause of these costs and implement a solution that could help to curb the costs to the plan. One such solution is Inspera Health, one of the only solutions that specifically focuses on people living with 5+ chronic conditions. Lee Murphy, CEO of Inspera Health adds, “Once you see this group, you can’t unsee it; it is the only portion of high cost claimants that can be proactively identified and engaged.”


Inspera focuses on people with 5+ chronic conditions because unlike tragedies, traumas, and specialty medications, this population can be identified and planned for year after year. Their average participant is 52 years old, has eight chronic conditions, and has been with their organization for fifteen years. This is significant because this population is likely not career mobile, meaning they will be on the plan year after year until they decide to retire.


Fixing the foundation, focused on fixing health.

As a solution, Inspera Health’s program takes a whole-person approach, walking hand-in-hand with those who have 5+ chronic conditions and connecting them to the intrinsic reason as to why they want to improve their health. Their program typically lasts 15-18 months and incorporates weekly face-to-face meetings with the focus of improving health.


Everybody who enters their program gets a health coach and a mental health clinical evaluation. The health coach and licensed mental health practitioner then work together to create an individualized plan for everyone in the program. The plan includes face-to-face time with health education specialists involving areas such as nutrition, sleep, fitness, financial, etc. Additionally, Inspera Health also refers individuals out to supporting providers. 75% of people are referred out to mental health health counseling which is done by the plan’s behavioral health network. 80-90% of people need to work on their fitness, so Inspera will pay for a gym membership and personal trainer.


“Behaviour change has to be sustained for plan value, we focus on building resilience over time through personalizing each plan and having participants identify and connect with the intrinsic driving force for them that will support continued engagement. At 12 months, over 80% of those we create a plan for are still actively engaged in improving their health,” said Lee Murphy.


Long-term impacts to the health plan structure.

Through their program, Inspera Health wants to completely transform individuals lives by helping them eat, sleep, move, and manage stress better. To determine the success of their program, they measure and score across twelve different dimensions - activity minutes, sleep, weight, physical health, mental health, health activation, BMI, blood pressure, total cholesterol, blood sugar, pain, social needs and engagement - which includes closing gaps in care. After 90 days, changes should begin to appear in people’s health allowing them to be more engaged and productive in their work.


Long-term, as a solution, Inspera guarantees a 30% improvement in health and a 30% reduction in claims equating to $40 million in savings for 250 participants with 5+ conditions. By identifying and addressing this population, Inspera can provide significant savings to the plan as well as improving the overall health of its members. In terms of the value Inspera Health brings, Lee Murphy adds, “If you don’t focus specifically on these members, you will just continue to pay for them as other point solutions can not address the complexity and vulnerability inherent in this population. A quick look at your data will confirm their presence, the economic potential to engage, and the inability of this population to successfully engage with other point solutions.”


We are proud to feature Inspera Health on the Granite List


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