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Rather than waiting for annual claims data to provide a picture of BH utilization, an adjusted risk management approach that incorporates real-time BH intelligence is essential to efficiently utilize existing resources and lower costs.

The COVID-19 pandemic fundamentally changed the landscape of behavioral health in the U.S. According to a recent study published in the JAMA Health Forum, utilization and spending rates for mental health care services among commercially insured adults increased by 38.8% and 53.7%, respectively, between 2019 and 2022. While it’s of course critical that individuals are actively seeking the care they need, this uptick is indicative of a seismic shift in population risk that requires a more holistic evaluation in the post-COVID era.

This “new normal” of increased demand requires a foundational shift in the way payors predict and address risk within their population. Effective risk management hinges on the ability to identify high and rising risk populations sooner and in an ongoing way. Rather than waiting for annual claims data to provide a picture of BH utilization, an adjusted risk management approach that incorporates real-time BH intelligence is essential to efficiently utilize existing resources and lower costs. Providing access to BH point solutions alone is not sustainable in supporting ever-changing needs within today’s member populations.

Why Health Plans Need a New Risk Playbook

The delta between pre-pandemic and post-pandemic risk means the traditional actuarial model health plans use is no longer sufficient to enable predictable population risk. Legacy processes and systems rooted in physical health have led to limited identification and decision support for complex BH management even though BH is a significant risk contributor. Evernorth reported that the 22% of members with a behavioral health condition drove 44% of the health plan’s costs. Despite its impact on total cost, many health plans have managed BH in a silo or carved out the operations completely.

Because BH is not fully taken into account when predicting risk, many critical activities have become more challenging for health plans. Those include optimizing benefit design models, staying competitive with employer customers, measuring network performance, and—in managed Medicaid and Medicare populations—receiving the correct reimbursements based on CMS guidelines and calculated risk scores. Failing to adapt foundational components of risk management to address this titanic shift in BH will significantly drive up costs for health plans well into the future. That’s why adopting a new risk playbook is so critical.

A Return to Predictable Population Risk to Achieve Outcomes & Lower Costs

The acuity spectrum for BH is continuous and dynamic, which is why real-time insight into population needs is key. The ability to effectively manage risk relies on the ability to identify rising risk BH populations earlier, supply interventions along the severity spectrum that lead to more appropriate utilization, and implement these new risk factors into the actuarial equation to remain competitive. The combination of identifying risk and applying the right resource levels is how risk is controlled.

NeuroFlow’s solution for health plans is designed to accomplish holistic risk management. The platform provides real-time intelligence on member behavioral health to offer more accurate pictures of population risk, enabling reliable cost predictions, program and network adjustments, and interventions at the member level before costs rise. Leveraging universal screening, guidance to relevant resources, clinical decision support, as well as suicide prevention interventions, NeuroFlow surfaces and supports members across a spectrum of acuity.

For example, one individual who joined NeuroFlow suffered for many years with severe depression and suicidal ideation. They tried unsuccessfully for years to find an in-network therapist who specialized in their diagnosis and also had availability for new patients. After gaining access to NeuroFlow and triggering an alert, a suicide prevention professional contacted this individual. They took the time to understand the person’s unique needs, and within half an hour, helped them navigate to an in-network therapist, specialized in their diagnosis. The NeuroFlow user described this level of proactive support as the “difference between living and not.” That is the impact that a holistic risk management solution can provide.

Real-Time Risk Management Creates New Opportunities

The ability to identify, engage, and risk-stratify members earlier in their care journey creates a slew of downstream benefits. Those include more accurate CMS reimbursements thanks to greater visibility into BH conditions. Payors will also experience improved utilization of programs and benefits, which not only prevents member escalation, but informs payors where to further invest. With richer insights, behavioral health providers and care managers can operate at top levels of efficiency, spending time with the members who need it most. Finally, robust risk management leads to lower total cost of care because behavioral health needs are more effectively addressed, keeping these members out of costly settings like the ED and inpatient hospitals. 

As health plans approach this new precipice of risk, innovative solutions can help them adapt more quickly, utilize resources more efficiently, and most importantly, help members lead happier and healthier lives.

Learn more about NeuroFlow’s solutions for health plans.

Robert Capobianco has extensive strategic and operational experience with tech startups and large corporate organizations. He has a proven history of developing innovative strategies that drive revenue growth and market leadership resulting in multiple exits through strategic acquisitions - collectively exceeding $200M in acquisition value. Robert has over 20 years of experience in the healthcare technology industry, helping health plans access and activate robust population analytics to build more comprehensive alternative payment solutions that reduce costs and improve outcomes. In his current role, Robert is the Chief Commercial Officer at NeuroFlow. He is responsible for defining and executing NeuroFlow’s long term commercialization and business development strategy.