What patterns were seen that caused the health plan concern

Reference no: EM133705933

Case Study

Consider the following case:

A national health insurance plan was concerned about its ability to influence the use of health services by its plan members. A review of utilization patterns suggested a high level of both overutilization of certain health services and underutilization of other health services. The patterns identified could be correlated with both inefficient use of services resulting in poor health outcomes and unnecessarily high costs to the health plan. The plan administrators developed a pilot program for addressing inappropriate utilization of services and began by focusing on substance abuse services. By examining existing patterns of utilization and plan member characteristics, they were able to identify segments of the population that were at risk for substance abuse or that were already substance abusers.

The research indicated the characteristics of those most at risk in terms of their demographic attributes and psychographic cluster (i.e., Mosaic segment). Plan administrators were able to develop materials targeting subsets of the plan population with information designed to resonate with their demographic and lifestyle attributes. This approach led to much better communication with targeted plan members and, ultimately, more efficient use of services and reduced health plan costs.

After reviewing the preceding case, address the following points:

Why was the health plan concerned about the health behavior of its plan members?
What patterns were seen that caused the health plan concern?
What were the implications of plan members' health behavior for the members' health outcomes and costs to the health plan?
What particular category of service user was identified for the pilot program and why?
What information did the health plan collect on plan members who were at risk for substance abuse?
How did plan administrators use this information to develop communication materials?
What was the effect of this pilot program on health services utilization and health plan costs?

Reference no: EM133705933

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