June 18, 2018

Could a Lack of True Post-Acute Standards Drive Billions in Neurological Claims?

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The Cost and Quality Consequences for Health Plans and Their Members

Although episodes of care have existed for decades, surprisingly for many common conditions, there still is no true post-acute standard of care. Among the most prevalent and costly of such episodes are those associated with neurological conditions, which drove a staggering $800 billion in annual U.S. costs according to a 2014 report cited in Neurology Today. A subset of six neurological conditions including stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, muscular dystrophy, and cerebral palsy drove $240 billion of these annual costs.

A Far Greater Challenge Than Previously Projected

It’s well documented that comorbid conditions such as cardiovascular disease increase patient complexity. However, a recent analysis found that when those complications occur in patients diagnosed with a primary neurological condition, specifically the above six neurological conditions, the clinical risk and medical cost may be even more significant. This is true both for patients and the health plans that serve them. , a 2018 claims analysis conducted by Utilize Health revealed that post-acute neurological episodes are far more common—and more costly—than previously understood by payors. Trends identified by the recent analysis showed annual growth of medical expenditures for neurological conditions can exceed 25 percent; significantly surpassing traditional health plan estimates.

Comparison: High Risk Cardiovascular vs. Neurological Post-Acute Journey

Consider for purposes of comparison, the established, post-discharge standard of care for a cardiac bypass patient:

  • Routine recovery time in hospital is on average a week or less for an uncomplicated procedure.
  • Once discharged:
    • Medical treatment is started or adjusted for the patient’s underlying conditions (e.g., statins are prescribed to manage underlying atherosclerotic disease; blood pressure medication is prescribed or adjusted to treat hypertension; aspirin is recommended to prevent clotting.)
    • Cardiac rehab is prescribed; generally 2-3 times per week for approximately six weeks.
  • Within three months of an uncomplicated coronary arterial by-pass graft (CABG), patients not only feel better and can be more active, but many can also return to a normal routine or even a vastly improved quality of life.

Now consider the typical post-discharge journey for patients with neurological conditions such as stroke, traumatic brain injury, spinal cord injury, multiple sclerosis, muscular dystrophy, and cerebral palsy:

  • Following a critical incident, diagnosis, and discharge, patients with the above conditions often disappear into the claims data while their underlying neurological needs remain unaddressed. A key example is that of a patient discharged following admission for a stroke.
    • The patient would typically be classified and managed post-discharge under a cardiovascular diagnosis.
    • However, neurological conditions and complications following a stroke can be highly debilitating, including hemiplegia, aphagia, aphasia, and gait disturbance, among many others.
    • Lack of consistent use of current, evidence-based guidelines and quality facility standards produce estimated patient recovery times that are inexact at best ¾ and far more disturbing, some patients are given no expectation at all of recovery.
  • So, while a patient’s primary cardiovascular diagnosis is managed ongoing via clinical best practice, these underlying neurological needs may remain inadequately addressed for decades.
    • Even for payors and providers actively seeking a solution, the complexity of neurological conditions is commonly hidden within claims, confounding the ability to accurately identify patient needs and establish true post-acute standards of care.
    • The result is that efficacy of care is often lacking despite high system utilization, and significant misdirection of clinical resources occurs because issues are viewed as short-term and episodic when instead they represent escalating events in a complex web of interrelated episodes.

Solution: Establishing a True Post-Acute Neuro Standard of Care

Current medical evidence supports that in order to optimize outcomes and care, the addition of a neurological classification aligned with a true post-discharge standard of care may be the key to cost effectively managing post acute needs for certain diagnoses. Further, evidence shows that outcomes could be significantly improved for many classes of patients with neurological conditions if therapies delivered post-discharge paralleled current advances in medical science and technology. 

Utilize Health applies current, evidence-based guidelines to establish a successful post-acute standard of care for neurological conditions. The Company’s expertise in neurological conditions and proprietary algorithms facilitate claims analysis to swiftly identify and target appropriate members within the health plan’s population. Utilize Health’s comprehensive analysis considers more than 80 data variables to identify complex neurological patients who can benefit from post-acute management and support.

Once identified, Utilize Health conducts cost effective outreach with specialized clinicians, who have a minimum of 8+ years of neurological care experience in at least two discrete care settings. This experience and expertise allows our clinicians to meaningfully engage the target member population, delivering a comprehensive care management assessment that includes:

  • Functional abilities/deficits in relation to the specific neurological condition
  • Therapy programs attended in relation to the specific neurological condition
  • The patient’s understanding of his/her own condition
  • The patient’s personal goals for recovery and overall health
  • Social determinants of health impacting ability and willingness to adhere to a plan of care
  • Medication adherence and other therapy adherence patterns

Utilize Health then develops an individualized care plan based upon assessment findings and matches each patient’s unique needs to specific therapies and services to help optimize results. This care optimization is accomplished via the Facility Finder—a unique, quality network management tool that leverages twenty-four unique data metrics, including specialty equipment; therapy modalities; and program and staff certifications to ensure the best possible match of member, condition, and facility. Utilize Health’s neurological Facility Finder is the only tool of its kind in the market.

Results: Quality Driven Savings of 15 to 20 Percent

Utilize Health’s results are proven, immediate, and have shown a 15 to 20% delta in care costs for clients. Total medical expenditures, depending upon population and lines of business served, can reach more than 20% of a plans overall spend. Funding models for Utilize Health programs are flexible and can include full fees at risk as desired by the client.

To learn more about how Utilize Health can help your health plan improve care, outcomes, and cost for members with neurological conditions, contact us today:

Lon Hecht, Chief Commercial Officer

Mobile: 732-539-6086

Citation: The Economic Burden of Neurologic Disease — $800 Billion Annually in the US; Shaw, Gina; Neurology Today, 17(12):1,14-18, June 22, 2017; doi: 10.1097/01.NT.0000521169.52982.7f.