SHPS, Inc.

Situation

Healthcare costs consume limited budgets and prevent funding of other important social services. As a result, state and federal governments have begun to focus on the root causes of healthcare cost increases and are seeking innovative ways to sustain public programs financially without cutting benefits and improve quality while managing clinical and financial risks.

Public programs, such as Medicaid, Medicare, and state health insurance programs for children, account for approximately 45 percent of total annual healthcare expenditures in the U.S. According to Congressional Budget Office projections, Medicaid spending alone will rise at eight percent over the next 10 years — from an estimated $192 billion in 2007 to $417 billion by 2017 — requiring additional state and federal funding of $225 billion. The Medicare program is also in financial jeopardy over the long-term. In 2017, the cost for Medicare will almost double, from $432 billion in 2007 to $853 billion in 2017. One significant factor reducing future available Medicare funding is the ratio of workers to beneficiaries, resulting in a reduction in tax revenues as baby boomers (people born between 1946 and 1964) begin entering the program next year. Tax revenues will slowly begin to decline as fewer workers contribute to Medicare funding.

Other factors affecting these programs are increased longevity, sophisticated healthcare technologies and increased drug costs, reduced private coverage for medical expense and long-term care, and the growing number of uninsured. Budgetary pressures and concerns that these important social programs will be unsustainable in future years are causing states and the federal government to look for viable reforms.

One solution is to change the way in which people purchase healthcare and manage their own healthcare behaviors — a combination of taking personal responsibility for health and becoming educated about individual consumerism.

The majority of healthcare expense is generated by chronic conditions. An estimated 100 million Americans live with a chronic condition — a leading cause of injury, illness, and death in the U.S. And, it’s estimated that 50 million more people will develop a chronic condition in the next 20 years. The list of chronic conditions varies with age and ranges from sinusitis to diabetes, and these conditions affect people emotionally, as well as physically. Hospitalization rates are higher for people aged 45 and older with a chronic condition, and conditions in the elderly are more disabling, requiring more care. To manage chronic conditions and care for diseases while simultaneously controlling healthcare costs and consumption, chronic care and disease management programs that leverage state-of-the art technology to measure risk, create electronic health records, and provide meaningful ROI health metrics are at the forefront of viable and effective solutions.

Solution

SHPS’ goal is to assist public programs in managing the clinical and financial risks associated with member populations. SHPS can help identify opportunities to manage future and current healthcare risk, reducing healthcare spend while improving the health of individuals. SHPS’ innovative solutions fundamentally change how we structure, staff, and deliver healthcare services from the ground up. Key drivers to better health outcomes and lower costs include:

• Understanding the health and financial risks of the population and the key risk drivers;
  
• Aligning policy and program design and targeting unique population needs;
  
• Developing interventions that address each individual’s health risks and prioritizing interventions based upon financial impact and the unique needs of the individual;
  
• Achieving integrated program delivery that provides a “person-centric” approach; and
  
• Providing comprehensive metrics to measure improvements.
  

Federal and state reforms are designed to reduce costs without unpopular benefit cutbacks or degradation in healthcare quality. SHPS provides services that support this approach and that offer significant effective methods that will reduce and control healthcare costs while supporting individual healthcare needs, coordinating with healthcare providers, and delivering quality healthcare programs that reduce risk.

Sustainable cost controls must consider a variety of unique components and yet create a common framework that reinforces and supports an environment that will address health and financial concerns. Personal health responsibility, underlying social issues, and appropriate technologies must all come together to realize a significant progress toward delivering quality healthcare programs.

Improving the clinical health of a population has a direct correlation to the financial reductions that can be realized in overall healthcare costs. Healthcare cost containment solutions that are built on changing personal behaviors and responsibility as well as delivering education around healthcare consumerism result in reduced utilization and overall better health for the individual.

From the healthy, to the disabled, to the frail elderly, SHPS’ care management programs help companies and individuals alike achieve these goals. Care management consists of three primary healthcare management programs: case management, disease management, and utilization management. We address the entire healthcare continuum with effective utilization analysis, scientific clinical solutions, and patient interventions that are determined through careful, thoughtful analysis and actuarially validated risk models.

The SHPS Model
SHPS has developed a solution for healthcare cost containment that uses a person-centric approach rather than a traditional disease-centric approach. By treating the whole person — not just the disease — and by working with care givers, insurers, government agencies, and community resources, individuals can be empowered to engage in healthy behaviors, better manage any chronic conditions or diseases, improve overall health, and become wiser healthcare consumers.

The individual’s care givers and healthcare providers must be included in the overall coordination of healthcare delivery and educational efforts to ensure program effectiveness. Oftentimes, integrating community-based services and behavioral health services into a person’s care plan is also necessary to ensure positive health and behavioral changes that improve an individual’s current and future health.

Costs associated with preventable diseases and chronic conditions — responsible for a large portion of public and private healthcare spending — can be better managed using a person-centric 360-degree patient view that results in reducing duplicative, uncoordinated, and inappropriate services. As a result, funds are freed up to help sustain the Medicaid and Medicare programs and, over the long-term, prevent a loss in benefits or increase cost sharing for individuals who cannot afford greater out-of-pocket costs.

Calculating the Risk
SHPS’ proprietary predictive modeling and analytics solution provides in-depth assessments of an individual’s health status and non-compliance with evidence-based medicine. Within a total population, we can identify the right population for enhanced support and the top drivers of healthcare utilization. Risk scores provide a baseline measurement to predict and verify future return on investment from reduced utilization and improved compliance with evidence-based medicine and other clinical guidelines. The ability to develop methods that improve service coordination and utilization, reduce duplication of services, and aid in the delivery of person-centric healthcare increases the quality of care and reduces consumption of services (e.g., hospitalizations, emergency room visits, unnecessary duplicative testing, etc.).


SHPS’ person-centric healthcare delivery model facilitates the coordination of all care and services, manages interactions, and maintains record-keeping for measuring results. Care providers, community resources, and other significant health-related entities, are integrated into an individual’s care plan and results are shared with providers to aid in care delivery. Armed with population analytics and clinical and financial risk data, including a proprietary health risk index that provides insight into the program’s true cost drivers, state and federal agencies can receive program data that allows them to design services that focus on maximizing the health and well-being of Medicaid recipients. The program’s success can be measured through reduced growth in spending.

eHealth Capabilities
SHPS’ 360-degree view of an individual’s healthcare history and current status is created by aggregating relevant information from multiple sources to ensure up-to-date information is available for decision-making. Data is collected from sources, such as claims, eligibility, lab data, biometrics, and health risk assessments, to develop a health record that can be shared with healthcare providers. Critical gaps in care, gaps in compliance to care, and over- and under-utilization of services are easily identified and help ensure the individual is receiving the right care at the right time.

Sharing the health record, risk factors, and care plans with care givers provides continuity of information and care coordination that will benefit the member, as well as reduce unnecessary healthcare expenditures.

For public and private healthcare programs, SHPS is dedicated to improving a health advocacy model that empowers and engages both the individual and healthcare providers. By working together, we can design a better model that addresses the future needs of our citizens and ensures that the necessary funding will be available for future generations. Breakthrough transformation is possible if we are proactive in building advanced person-centric solutions.

We can work toward change and building an infrastructure that promotes and rewards healthy behaviors rather than being reactive to health changes and treatment of diseases. We can improve efficiency and care delivery by providing connectivity to electronic health records rather than inefficient recollection of patient information and lack of comprehensive patient health records. We can leverage technology to close gaps in care, break down disconnected silos, and reduce overall healthcare consumption.

Better Health, Lower Costs

In developing a program for measuring results, a healthcare strategy should:

• Measure the entire program through total population analysis and risk identification;
  
• Provide actuarially validated risk score and metrics;
  
• Properly align incentives and determine measurable outcomes;
  
• Measure individual risk and develop appropriate interventions that reduce individual risk;
  
• Ensure healthcare providers, care givers, and family members are involved in the individual’s care when possible;
  
• Educate and support individuals to make significant progress toward personal goals, work toward changing behaviors, and change inefficient healthcare consumerism habits;
  
• Provide an electronic health record to ensure holistic care and facilitate information and communication between providers;
  
• Include personal nurse line and clinical coaching, especially for high-risk individuals;
  
• Communicate wellness and health education in a timely manner and build in supportive, motivational communication with program members;
  
• Provide real-time insight into opportunities for interventions on an ongoing basis; and
  
• Allow for flexibility to address future change, respond to new regulations, incorporate emerging technologies, and address individual healthcare needs.