Leveraging Predictive Modeling, Data Analytics in Member Health Management

In managing the care of patients with chronic conditions, who represent 90% of all health care expenditures and costs, there exist several actionable interventions that can help close gaps in care, provide site of care recommendations, and even reduce the cost burden.

Focusing on predictive modeling and artificial intelligence, , spoke During a session at Asembia 2021 Specialty Pharmacy Summit, Erika Glenn, Division Head of Sales, Care Management, CVS Health, focused on notable contributors to cost, predictive modeling and artificial intelligence, and how these innovations can work to positively influence member decisions in choosing more efficient care options.

Notably, 30% of the health care expenditures tied to chronic conditions are attributed to avoidable emergency department visits, with issues such as health literacy potentially contributing to these admissions.

Adopting a personalized strategy to each member that is informed by data analytics, Glenn said that her organization compiles prescription claims, medical claims, lab results, and data on social determinants of health.

“All the different data elements that we can potentially find about these members. We essentially kind of take them and consume them into an engine,” she said. “What makes us a little different about what we do is risk stratification….We are looking to understand for each individual member how we specialized care they create custom carefully if you will for that person.”

As more information is input into the engine, it takes on a machine learning approach that creates an integrated experience tailored toward the preferences of individual members.

“We really want to take in all the data points and data elements that we can, understand what those risks are, try to consort those out into segments, and figure out what we want to pursue first.”

Glenn said CVS Health provides patients with a variety of different care options that can assist in identifying risks and providing low-cost interventions. During a 1-on-1 patient-pharmacist visit, referred to as the pharmacist panel, patients can get a full wellness check, with other additional features, such as the Minute Clinic and Health Hub, supporting a holistic health care approach for members with chronic conditions.

“We’re also looking at where some of those behavioral changes occur. We're doing tests to learn this per individual member. So, lots and lots of studying around individuals and making sure we're getting all that data in the hands of clinicians to help all of these members.”

Understanding not only the right channel to provide care, but the right messaging that best resonates with individual members can help improve patient outcomes, added Glenn.

“The other piece to all of this is as we move into specialty conditions, CVS Health believes it's very important to reach out to every member, not just the top 25%, not the top 25 sickest specialty members,” she concluded. “Really trying to take a step back and looking at all the different ways in which we can understand the payers, understand that behavioral changes, and make sure we're driving results.”