Common Scenario: Diabetes and comorbid conditions overlap.
This chart shows the average health segmentation of a typical health plan. The percentage of population and represented cost associated with the chronic disease burden. While 20% of the population are Non-Claimants (blue), 36% are Claimants (red) experiencing Conditions that are Acute (Non-Chronic), 20% of the population has one chronic condition (brown), while 24% of the population is polychronic/2 or more chronic conditions (yellow). The chronic disease burden population has significantly higher costs, where 24% of the population is over $2.3M versus those members experiencing Acute conditions at just over $300K.
The chronic disease burden associated with chronic and lifestyle conditions are significant contributors to driving health care costs. Costs and risk associated with chronic disease continue to rise. While also a reflection of population health, many chronic conditions are preventable, such as adult-onset Type 2 Diabetes. However, when a person is diagnosed with T2 Diabetes, it is not reversible except in certain situations (for example, bariatric surgery). It becomes a chronic condition that a person must deal with for the rest of their life.
Not Addressing or Preventing Progression of Chronic Disease
3 Proven Ways to Save a Significant Amount of Money on Employee Benefits
Specialty medications adjudicated as pharmacy claims or medical pharmacy claims (“J-Code” or Non-PBM drugs) can account for over 50% of the pharmaceutical expenditure for a health plan, while typically less than 5% of their membership is on specialty medication. These medicines have become a predominant driver of large claims. Specialty medication trend is now double-digit. These drugs are on the rise for treatments of certain conditions like Adult Rheumatoid Arthritis, Psoriasis, Multiple Sclerosis, and even a common condition like Diabetes.
Carve out pharmacy benefits to a pharmacy benefits manager or a third-party vendor focused on specialty drug costs. There are programs designed to reduce or eliminate the cost associated with specialty drugs driving cost for a health plan. But first, you must carve out the drugs from the medical plan. Then, carving out specialty drugs from the PBM with point solutions that reduce cost for members and the plan that require specialty medications. Alone, these programs can impact the overall health plan by reducing overall health plan costs by 11% or more.
Not carving out Rx or focusing on Specialty Medications
Provider Profiling to Create Narrow Networks and use of Providing Medical Pricing Transparency Tools.
Due to the lack of transparency of health care costs, many high-volume procedures and billing practices cause huge discrepancies in costs for services which are at the heart of overspending. Lab work, imaging, and outpatient facilities tend to be more cost effective outside the hospital setting. In many cases, facility providers account for the majority of costs and there is s For example. In this case, you can see the wide variance in cost associated with a simple colonoscopy procedure.
Failure to Evaluate Provider Network Performance
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Data shows that Diabetes does not often occur in isolation.
98% of diabetics have at least one co-morbid condition while 90% of diabetics and more than one co-morbid condition (2+).
The three most common co-morbidities associated with diabetes are hypertension (high blood pressure), hyperlipidemia (elevated cholesterol), and elevated BMI (overweight).
Followed by other more serious comorbid conditions such as cardiovascular disease (heart disease), blindness, lower-extremity amputation (due to insufficient blood flow), and kidney disease (which may progress to dialysis).