How care navigation lowers costs for high-risk members

With healthcare costs on the rise, over half of employers are prioritizing strategies that reduce spend on their highest-cost members. These members account for nearly 50% of healthcare spending despite being a small segment of the population. Clinical navigation solutions have emerged as the key to effectively managing high-cost members and significantly reducing their healthcare expenses.

At Rightway, we leverage our cutting-edge technology and deep clinical expertise to make a meaningful difference in both the outcomes and costs associated with these members.

Here’s how we do it:

1. We identify high- and rising-risk members using a data-driven approach.

Our strategy is anchored by a proprietary risk-scoring methodology that identifies high-risk or rising-risk members. High-risk members typically have two or more chronic conditions and have used acute care or the emergency department in the past year or have had a healthcare spend over $50,000 in the past 12 months. Rising-risk members are those with a projected $30,000 to $50,000 in healthcare expenses over the next year, have one or more chronic conditions with no ambulatory care in the past 12 months, or are over 45 years old without ambulatory care in the past year. We determine a member’s risk based on:

Medical and pharmacy claims: Our machine-learning algorithm analyzes each member's medical history using medical and pharmacy claims data. This data includes demographics, diagnoses, procedures, prescriptions, and historical healthcare spending, helping us identify active or deteriorating conditions.
Member health surveys: These surveys provide insights into self-reported conditions not captured in claims data and behavioral and lifestyle information such as nutrition and exercise habits.
Health guide interactions: Insights from conversations between a member and their health guide also inform our understanding, especially if a member discloses having a chronic or acute condition during these interactions. Health guides know the right questions to ask and follow up with them to ensure they capture the complete picture of each member's health.

2. We track essential gaps in care.

Gaps in care can take many forms, such as missed screenings, overdue wellness visits, or inconsistent medication adherence. These gaps can worsen chronic conditions and preventable diseases, negatively impacting member health and increasing costs.

Rightway proactively identifies members who may be missing crucial healthcare interventions, such as annual primary care visits, essential vaccinations, cancer screenings, or diabetes monitoring. 87% of Rightway members visited a primary care physician last year, which is 11% higher than the national average. By addressing these gaps early, we help prevent conditions from escalating into more severe health issues that drive up healthcare costs later on.

3. We provide tailored clinical guidance and support.

Once we identify high-risk and rising-risk members and members with care gaps, our clinical health guides take a proactive and personalized approach to educating members on their conditions. They help them adhere to their medication schedules and ensure they follow through with recommended treatments and screenings.

We don't wait for these members to reach out; instead, we proactively engage them directly through various channels such as phone, in-app alerts and notifications, text, email, and even personalized mail. When a health need is recognized, a Rightway health guide steers the member toward the highest quality, most cost-effective, and appropriate site of service and type of care to lower costs. Patient navigation ensures that members receive high-value care and reduces the likelihood of costly readmissions and complications, ultimately leading to significant downstream savings.

Care navigation creates tangible reductions in healthcare costs.

Rightway's clinical navigation services provide a strategic advantage to employers looking to lower healthcare costs by transforming how high-cost members interact with the healthcare system. Our data-driven approach, combined with proactive, personalized clinical navigation, ensures that high-cost members receive the care they need before reaching a crisis point, effectively managing and reducing healthcare costs.

To see how our high-risk patient navigation services saved one client $524K in healthcare costs in one here, click here.