Payers Embrace Chronic Disease Prevention To Reduce Costs

By Infinx
January 22, 2018

It would be easy to think that payers don’t really concern themselves with chronic disease prevention unless it’s on an actuarial table. The reality is that insurance companies are actively participating in the larger healthcare industry effort to reduce chronic disease as an effort to reduce healthcare costs. In this blog, we’ll review the CDC’s Four Domains of Chronic Disease Prevention and examine the steps payers can take to implement these guidelines to reduce costs and promote patient health.

CDC’s four domains of chronic disease prevention

The Centers for Disease Control (CDC) developed its Four Domains of Chronic Disease Prevention system to find ways to address chronic diseases. The CDC says that heart disease, stroke, cancer, type 2 diabetes, and other conditions are “major drivers of sickness, disability, and health care costs” in the United States. Proactively addressing the risk factors for these diseases can reduce the incidence of the diseases themselves, thereby reducing costs. To the extent that providers participate in this system, patient care improves, and reimbursements for quality care may climb as well.

The four domains of the CDC system are:

  1. Epidemiology and surveillance: methods used to track chronic diseases and their risk factors.
  2. Environmental approaches: changes in policies and physical surroundings to make the healthy choice the natural choice.
  3. Healthcare system interventions: improvements in care that allow doctors to diagnose chronic diseases earlier and to manage them better.
  4. Community programs linked to clinical services: those that help patients prevent and manage their chronic diseases, with guidance from their doctor.

Improving chronic disease interventions

While payers are well aware of the four domains of the CDC system, the third domain — Health Care System Interventions — may have the most impact. It promotes chronic disease interventions that increase the use of clinical and preventive services while also improving their quality. High-quality programs and access to care lead to early detection of disease and the effective reduction of risk factors like high blood pressure, smoking, poor diet, and lack of exercise. They can also manage complications to avoid expensive, adverse health events that require hospital stays and costly imaging.

The CDC recommends several actions to implement the goals and objectives of the third domain, and payers may or may not embrace them according to how significantly the changes might affect corporate policy and individual coverage costs:

  • Expanding coverage of preventive services
  • Improving payment for care
  • Increasing the use of health information technology
  • Improving measurement of successes and failures

These actions also encourage removing barriers to improve access to care for underserved populations. Payers can’t tackle all of these issues, but increasingly they are trying to develop programs that help to manage chronic conditions in their subscriber base proactively.

Data-driven improvements

Payers are turning to data to determine how to manage chronic disease best. One report describes how Anthem is using data from multiple sources to analyze the health risks, behaviors and lifestyle habits of members that contribute to chronic disease. It’s not an inexpensive exercise. These analyses require causal and machine learning, transforming enormous amounts of data into meaningful findings and using predictive analytics to deliver actionable trending information. The result is valuable insights into member behaviors that can be adjusted to avoid chronic disease.

HealthIT Analytics reported on the wealth of data that Anthem uses to gain member insights. It combines “claims data with clinical data, electronic health records, lab results, and patient-generated data from its website and call centers” into one integrated data warehouse. Once these data are analyzed, Anthem has a better understanding of each member’s risk factors, likelihood of developing chronic disease, and even what lifestyle factors can be changed to avoid developing, or worsening, chronic disease states.

Understanding population health

The CDC’s third domain of chronic disease prevention also recommends that payers and providers work together to address population health factors. This matters because heart disease, cancer, lung disease including emphysema and chronic bronchitis, stroke and unintentional injuries like car accidents and overdoses cause nearly 900,000 deaths annually in the United States. They are also big-ticket items for the healthcare industry, (not to be too capitalistic about it, but the goal is to reduce costs). The striking statistic is that more than a third of the deaths from those factors are preventable.

The first step in implementing population health strategies that reduce chronic diseases is to improve access to preventive care. Payers can make a big difference in this area, using member risk analysis to develop outreach and education programs that improve member lifestyle behaviors. Effective strategies include:

  • Adjusting coverage for preventive services like nutrition counseling, gym memberships, screenings, etc.
  • Adopting value-based insurance design
  • Member education

Value-based insurance design

It’s worth a moment to look at value-based insurance design because pricing can increase access and improve health behaviors. This strategy uses financial incentives to increase the quality of healthcare and reduce costs through:

  • Offering cost-effective healthcare services that entice consumers
  • Providing enhanced services that improve enrollee health
  • Increasing preventive care services and medications that control risk factors

These strategies can help to avoid future expensive health events, and reduce emergency room visits and incidence of chronic diseases.

Implementing the four domains

By implementing the four domains of the CDC system, payers will not only be joining the larger healthcare chronic disease prevention efforts but also accomplish their goal of reducing healthcare costs. Some large-scale payers are already using their vast data-gathering systems for disease prevention for their members. And others are actively promoting community programs that tie at-risk populations to clinical services.

We have known for some time that it was going to take all hands on deck to make significant changes in the healthcare delivery system and reduce costs. The payer-provider-patient partnership may just be the giant leap forward that we’ve been waiting for regarding chronic disease prevention and cost reduction.

About the Author



Infinx provides innovative and scalable payment lifecycle solutions for healthcare practices. Combining an intelligent, cloud-based platform driven by AI with our trained and certified coding and billing specialists, we help clients realize revenue, enabling them to shift focus from administrative details to billable patient care.

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