How Engooden Lowers Risk for Stakeholders

By Ryan Atwood
Vice President of Payer Relations and Regulatory Compliance

America is currently confronting a massive healthcare problem. The American Hospital Association is projecting a shortage of up to 124,000 physicians by 2033 which – when combined with a rapidly aging population and a steady increase in the number of people with at least one chronic disease – will come together to create the perfect storm. Without significant changes, the tidal wave of patients aging into Medicare, combined with the shortage of primary care physicians is going to quickly overwhelm the healthcare system. But it’s not just providers and patients that will feel the impact. Payers - especially Medicare and Medicaid - play an important role in how we will weather this storm, and there are measures that payers, along with their provider partners, can take today to mitigate its effects.

The Importance of Closing Care Gaps
A recent study
found that more than 4 million annual emergency room visits by patients with chronic conditions were potentially avoidable. The same research advises that avoiding these ER visits could have saved the healthcare system over $8 billion annually. Part of what is driving avoidable visits is an information gap. The information patients and providers discuss during primary care visits is often strictly clinically focused, which is important to resolve acute issues but, by focusing only on this type of information, care teams aren’t learning about the significant, non-clinical barriers that can severely impact patient’s ability to improve their underlying health status. Understanding a patient’s social determinants of health like economic stability and access to quality education are crucial in creating robust, effective care plans for patients, especially those living with multiple chronic conditions.

Effectively engaging patients outside of traditional care settings to identify and address clinical and non-clinical health factors is an essential step towards influencing patient outcomes and lowering the risk of acute health episodes. As more care shifts to value-based models, providers are now being held financially accountable for the clinical outcomes that are driven by the 80% of health factors over which they have no control (and not just the 20% driven by clinical care). It is essential for organizations participating in value-based care (VBC) programs to be proactive in transforming their care delivery model to include more frequent, proactive engagement with patients. Creating programs that more efficiently and effectively manage and mitigate the effects of chronic diseases, while promoting patient wellness help to reduce the likelihood of severe illness – and reduce overall healthcare costs. Furthermore, if providers experience an information gap, it’s all but certain that payers are missing critical information, too. Payers also need a consistent level of engagement in order to design and deploy more effective plans and programs to support patients as their needs change.

The Centers for Medicare & Medicaid Services (CMS) has made chronic disease management a bigger priority, starting in 2015 as a mechanism to improve population health. Over time, it has become clear that preventing patient health status from getting worse requires engaging them outside the doctor's office. Gaining better insight into patient health status is essential to getting them the care they need, and it also helps payers understand the risk profile of patients to build better programs to support patients at an individual level. This is not only the appropriate thing to do for member health, but also can help to reduce the significant financial impact to payers and the overall healthcare infrastructure. Payer organizations, including Medicare and Medicaid, can significantly mitigate their exposure to risk across multiple domains by more effectively partnering with provider organizations that utilize a care delivery model that is based on proactive and consistent engagement with patients.

At Engooden, we excel at connecting with patients and helping them share information that gives a more complete view of the patient’s health status - including community context, health access and other factors that influence their health outcomes. In most practices, this kind of information often does not get shared with healthcare providers for various reasons. By building patient trust, we uncover the factors that most impact their health status and can share the information back to payers and providers, creating a more complete picture of patient wellbeing.

Mitigating risk with Engooden
In our model for working with payers and ACOs, we help healthcare providers identify the patients with multiple chronic conditions and at the greatest risk of shifting from rising-risk to high-risk status, and our care navigators address care gaps with proactive, personalized outreach every month. We are the only organization working to mitigate the impact of the perfect storm by building technology-enhanced workflows to address patient needs across the risk spectrum, from traditional fee-for-service to capitated population management.

Our care navigators use proprietary technology to seamlessly extend care into patients' homes. Through consistent conversations, our care team establishes genuine, trust-based connections with patients, gaining better insight into their health to improve patient experience and clinical and financial outcomes. Other benefits of this model include:

  • Increase visibility into rising-risk populations and those with managed chronic conditions to keep this cohort healthy
  • Reduce preventable acute events and downward care transitions
  • Reduce the total cost of care and organizational risks associated with chronic conditions
  • Create trust-based personal relationships with patients
  • Add concierge services to make plans more attractive and improve member enrollment and retention
  • Optimize enrollment for Medicare Advantage plans leveraging monthly engagements and conversations about health goals and benefit needs

By partnering with Engooden Health, payers gain an extra line of security from escalating costs associated with rising-risk patients. Connect with us or join our upcoming webinar to find out how we can help you improve patient health while achieving lower costs.