Earlier Signals, Better Outcomes: Rethinking Risk Stratification for New Members
Becker’s Healthcare PodcastSummary
Carla Mills, Vice President of Product Innovation at SureScripts, emphasizes the importance of effective risk stratification for health plans, particularly during the influx of new members in January, referred to as "blizzard season." She highlights the challenges faced by health plans, including time lag and fragmentation of claims and clinical data, which hinder timely risk assessment. Despite advancements in payer-to-payer APIs and upcoming mandates, a gap remains between policy and operational reality, complicating the prioritization of care for new members.
Mills discusses the value of medication data as an early signal for identifying members at risk. An analysis of 20,000 patients revealed that a significant percentage had chronic conditions and comorbidities, underscoring the need for proactive engagement. By leveraging medication patterns, health plans can identify members who may require immediate attention, allowing for timely interventions that can improve health outcomes and reduce costs.
To prepare for the upcoming "blizzard season," Mills suggests a three-point checklist for health plans: reassess data strategies to include timely indicators, utilize medication signals for early risk identification, and enhance operational execution to prioritize member engagement from day one. She advocates for a shift from managing symptoms to solving underlying problems in healthcare, urging leaders to optimize existing programs and make medication data more accessible to improve outcomes.
Show Notes
In this episode, Karla Mills, Vice President of Product Innovation, Surescripts, discusses how health plans can use medication data as an early signal to identify risk, prioritize new members, and improve care management. She shares practical strategies for preparing ahead of enrollment surges and leveraging existing programs to drive better outcomes and operational performance. For more information, please check out our website: https://surescripts.com/who-we-serve/health-plans
More from Becker’s Healthcare Podcast
In this episode, Ryan Mezinger, Senior Vice President and Chief Pharmacy Officer at MetroHealth, and Dr. Amit Gir, CEO and Co-Founder of Phox Health, discuss how MetroHealth's pharmacy delivery model is improving medication access, adherence, patient satisfaction, and care continuity while strengthening chain of custody and pharmacy operations.
In this episode, Dr. Kyle W. Trecartin, Chief Medical Officer, Beth Israel Deaconess Hospital - Plymouth, discusses improving patient throughput, strengthening quality and safety through a just culture, and expanding access to care in the community.
In this episode, Erica Rowe Urquhart, MD, PhD, Orthopedic Surgeon, Author, Healthcare Thought Leader, discusses how reimbursement pressures shape independent medical practices, why physicians must understand healthcare finance, and the leadership skills needed to sustain quality patient care.
In this episode, Dr. Sanjiv Shah, Chief Medical Officer, MetroPlusHealth, discusses how care management, provider partnerships, and timely information exchange have helped MetroPlusHealth earn consecutive four star Medicare Advantage ratings. He also shares strategies for closing care gaps, improving transitions after hospital stays, and preparing providers for digital quality reporting requirements.
In this episode, Dr. Alice Chen, Chief Health Officer at Centene, discusses how health plans can use evidence based prevention frameworks to improve outcomes, guide investments, and reduce waste. She shares lessons from food as medicine initiatives and explains why interventions must be supported by rigorous data, tailored to underserved populations, and proven effective before scaling.