Understanding Risk to Improve Quality of Care

It goes without saying, understanding your members’ risk is as crucial to delivering high quality care as it is to your plan’s financial success. Under the Hierarchical Condition Categories (HCC) reimbursement system, health plans must identify high-risk members to receive the payments necessary to cover that risk. But, assessing members’ risk status can be a challenge, especially if they are not actively engaged in their health or with the healthcare system.


Identifying Risk and Deploying a Winning Engagement Program

In this case study, we partnered with a large health plan to implement a targeted HCC identification and risk adjustment strategy. Our approach? A first-class engagement program.

As our first step, we identified high-risk members through propensity modeling and analytics. With this data in hand, we drilled down to yet another layer of detail, segmenting these members further based on risk score and propensity to activate. This allowed us to establish marketing focus, developing unique communication, and activation strategies per segment to drive either health risk assessment (HRA) completion or a primary care visit to assess risk. Not only does such a targeted approach make our solutions more effective at driving members to complete desired activities, it also makes them far more cost-effective as well.

Finally, as a key part of the process, we leveraged rewards and incentives to motivate members to engage and complete their HRA or visit their doctor. And, as always, we continuously learn and improve our engagement efforts based on how members do (or don’t) engage and the program results. As a program continues into its second year, we rely on data to inform any revisions to the model, further optimizing our communications and rewards strategy.


A Clearer Understanding of Members to Drive Future Action

By activating 17% of the health plan’s population, we were able to achieve over 11,000 completed HRAs. Further, we uncovered previously unidentified conditions for 12.8% of the engaged population. 


activated members


completed HRAs


increase in revenue

For an engagement program that effectively identifies risk, determine the optimal activation approach based on the member’s risk score and likelihood to engage. Invest resources accordingly and continuously refine the process by learning from member activity and non-activity. Lastly, focus on driving health actions with the highest value, like completing an HRA.