The Centers for Disease Control and Prevention estimates that chronic and mental health conditions — many of which can be avoided or mitigated through preventive care — account for 90% of the $4.1 trillion spent annually on healthcare in the United States.

Passage of the Affordable Care Act in 2010 made preventive care services more affordable for tens of millions of consumers. It mandated that most health plans cover a range of preventive services — from colonoscopies and mammograms to shingles vaccinations — at no cost to the member (when the member’s age and demographics are appropriate for the services).

Preventive care is a win-win for employers’ budgets and employee wellbeing. Still, some research shows surprisingly low utilization. A 2018 study by a team from the Agency for Healthcare Research and Quality found only 8% of adults ages 35 and older had received all high-priority preventive services recommended for them. Nearly 5% hadn’t received any of the services.

Partnering on preventive care utilization

HR and benefits professionals face a dual challenge when it comes to preventive health: First, ensure that benefits plan language stays current with evolving recommendations and requirements. Second, drive greater awareness and utilization among members.

To keep preventive care top of mind with members, HR teams can lean on benefits administration partners for support. In its 2020 Preventive Care Guide, Business Group on Health points to navigation companies and other partners as among employers’ primary opportunities “to drive appropriate and timely preventive screening utilization.”

Denise Wagner, BA, RN, CCM and a Quantum Health clinical manager, agrees that promoting preventive care should be a collaborative effort. “An employer’s benefits team can only generate so much momentum and motivation during open enrollment and over the course of a plan year.” Wagner said. “It’s the partner or partners that provide day-in, day-out member services and condition management support that really are best positioned to guide members to the specific preventive services they should be receiving.”

Guiding members to — and through — preventive care is a focus of Quantum Health’s healthcare navigation and care coordination solution. Navigation Insider recently spoke with Wagner to learn some of the ways the company’s engagement model and proprietary technology platform work together to boost utilization.

“An employer’s benefits team can only generate so much momentum and motivation during open enrollment and over the course of a plan year.”
-Denise Wagner, BA, RN, CCM

Prioritizing the primary care provider (PCP)

Research shows that consumers who don’t have a PCP relationship are more likely to eventually visit the emergency room or become hospitalized. One study found that a member without a designated PCP can end up incurring 33% more in claims costs than a member with one. Why? For one reason, members who lack a PCP might seek costlier, unnecessarily advanced levels of care (e.g., the ER, a specialist) when they have a healthcare need.

PCPs play a pivotal role in monitoring and assessing patients’ physical and mental wellbeing and making clinically appropriate referrals to specialists. Given that, Quantum Health’s solution consistently prompts members to designate an in-network PCP.

When a member without a PCP relationship contacts Quantum Health for any type of benefits assistance, the company’s platform prompts a Care Coordinator to ask about (and attempt to complete) a PCP designation. To make it easy for the member, the Care Coordinator will research a list of in-network family practice physicians, internists, or another PCP-appropriate type of provider conveniently located near the member’s home or work.

Spotlighting recommended preventive services

Within each member’s electronic record, an algorithm visually alerts Care Coordinators to a personalized list of preventive services the member should receive, based on their age, gender and health risk factors (if any). These same services are spotlighted when members access benefits and claims information via the mobile app provided by Quantum Health.

A single mouse click lets the Care Coordinator access and explain the member’s plan-specific benefits coverage. During the conversation, they will probe to uncover and problem-solve any barriers (such as social determinants of health) that might prevent the member from following through on preventive care. It’s all done to encourage and assist in getting recommended services scheduled and completed.

Filling care gaps

In Quantum Health’s navigation model, members living with chronic conditions are assigned to a Personal Care Guide (PCG) nurse for one-on-one engagement. The PCG nurse focuses on helping the member with condition education, treatment plan adherence, and other types of clinical support and benefits guidance.

The PCG nurse also works to avoid and close gaps in preventive care, using the technology platform to closely monitor all routine services and screenings the member should be receiving. Missing a routine flu shot, for example, could put an already at-risk member at greater health risk, given the comorbidity presented by their chronic condition.

Persistent measurement

To help employers track progress on preventive health, Quantum Health regularly communicates both routine (e.g., annual physicals) and preventive care utilization in performance reports to clients. Services tracked for each client’s member population include breast, cervical, colorectal and osteoporosis screenings (for age- and gender-appropriate members), as well as flu and pneumonia vaccines.

Looking at prevention across all the members it serves, Quantum Health recently analyzed 2016 through 2019 data to evaluate trends in 17 quality metrics that measure preventive care utilization. Examples include “women age 25-65 with recommended cervical cancer screening,” and “annual flu vaccination (all ages).” All 17 metrics showed improvement between 2016 and 2019.

“The employers we work with definitely recognize the positive impact prevention can have on outcomes and costs,” Wagner said. “But they also know it takes persistent, effective engagement — educating and guiding members in the context of their daily experience consuming healthcare and using benefits. That’s the key to keeping utilization growing toward levels we’d all like to see.”

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