Achieving Better Outcomes, Lower Cost with a Healthcare Benefits Management Partner

Date: 2019-06-21

The healthcare industry is changing. From a rapidly increasing number of technological advancements to new state and federal rules and guidelines, the healthcare landscape in the United States continues to evolve and expand. That industry growth doesn’t appear to be changing anytime soon. In fact, it’s expected to grow even faster, adding more jobs between now and 2024 than any other sector.

Just as the world of healthcare continues to change, so do your needs and the choices available to you. Utilizing a healthcare management solutions provider that offers comprehensive and customizable services is essential to your growth and sustainability.

When choosing a partner to work with, there are many facets to review. One thing to consider is looking for a partner who has experience working with the populations you serve. You also may want to evaluate partners with success serving government-sponsored healthcare like Medicaid and Medicare. Partners with this type of experience are able to manage and deliver improved outcomes desptie tight budgets, tough government regulations and populations who may have higher-cost disease states.

Navigating the comprehensive healthcare management landscape can be difficult and timeconsuming. It’s key to ensure you have a good knowledge base before you begin looking at options and evaluating partners.

Empower Your Members

Your partner should work with you to help you empower your members to become active participants in their health. Individuals who take a vested interest and participate in their health journey achieve better outcomes, often at a lower cost. A study conducted by Health Affairs found that members who received enhanced decisionmaking support with their healthcare had overall medical costs that were 5.3 percent lower than those receiving only the usual support.  

Additionally, those members also had 12.5 percent fewer hospital admissions. Utilizing appropriate resources such as cancer screenings and testing for diabetes and cholesterol can help alert members to possible health issues and address those earlier on. Investing in preventative care may help them reduce their likelihood of developing costly, chronic conditions. Benefits of members actively participating in decisions that affect their health include:

  • Increased member satisfaction
  • Higher quality of life
  • Reduced anxiety and emotions
  • Better understanding of personal requirements
  • Increased trust in services due to increased freedom, knowledge and transparency
  • Enhanced member empowerment 

One thing is certain—when it comes to quality healthcare services, a one-size-fits-all model isn’t the answer. Your focus should be on providing healthcare services that address the whole person, not just one aspect of a person’s healthcare needs. Members will respond well to an integrated and flexible approach that connects traditionally fragmented services and links them to the appropriate medical and community resources.

Positive health outcomes are directly impacted by a member’s environment and access to education and assistance as it relates to their health decisions. People who struggle to meet basic needs such as food, housing or transportation find that behaviors and consequently, good health outcomes,are harder to achieve. By identifying these social determinants of health, you are better able to provide solutions for your members to help them live a healthier life. Also, assisting them in overcoming barriers helps their health and therefore enhances their involvement in and loyalty to your health plan.

A recent study showed that 90 percent of Medicaid plan respondents are faced with addressing not only the need for primary care access but also situations that factor into social determinants of health—which impacts their members ability to become, and stay, healthy.

This is just one proof point that there is a strong need to address social, physical and environmental issues to be able to achieve quality health. Choosing a partner with experience in overcoming barriers and continued efforts to identify and improve social determinants of health will help your plan’s members experience not only better health but a better overall life.

Integrated Services in Action

Working with a single partner for supplemental benefits can be beneficial for both the plan and member. The following are some services you might consider combining to better serve your members and reduce your costs.

Pharmacy Benefit Management (PBM)

PBM services designed to significantly improve how your business manages its pharmacy program improve financial, clinical and operational performance; cut wasteful spending; assist in managing cost trends; and ensure medication adherence within your population. Those that include progressive total drug management services maximize the value of your members’ health benefits, improve care quality and contain costs.Health plans are challenged with helping their members get access to necessary medications while keeping prescription costs down, even as medication costs continue to climb. Spending on prescription medicines in the U.S. is forecasted to reach $580-$610 billion in 2021. However, having a partner with strong data analytics and experience can help manage growing spend. More than a traditional PBM is needed to make a difference and impact. Your partner should be able to offer you a clinically sound, multi-pronged solution to maximize savings while ensuring member satisfaction. Also, PBM solutions must be able to deliver personalized drug management offerings to health plans and the individuals they serve.

Specialty Pharmacy

Most health plans face specialty drug management challenges, including rising drug costs, fragmented management, misalignment, and prescriber and member accountability. Trend reports show that specialty drug prices continue to increase and that the average retail cost of a single specialty drug therapy is more than $55,000 per year. Additionally, there is the problem of specialty medications being misused and underutilized—lessening their effectiveness and the health plan’s investment.

Successful specialty pharmacy partners are able to address these challenges because they’re equipped to monitor and track specialty drugs used in treating numerous critical and life-threatening diseases. They help educate health plan members to ensure the medications are being used properly and keep in touch with them throughout their treatment. In addition to these benefits, it’s been reported by the Pharmaceutical Care Management Association (PCMA) that specialty pharmacies and their PBM counterparts will save both payers and their members an estimated $250 billion over the next 10 years on the cost of specialty medications.

A healthcare solutions management partner should take a collaborative approach to specialty drug management and utilize member-centric and protocol-driven clinical data collection methods. Doing so can deliver measurable results and identifiable savings to payers and their members. Such a partner also ought to offer flexible, custom and comprehensive specialty pharmacy solutions designed to meet the needs of any population.


Vision benefits are about more than just eye exams and glasses. They are about offering a way to detect more severe eye issues and screen for more serious illnesses such as diabetes or high blood pressure. By catching illnesses before they progress, treatment costs can be reduced, and outcomes can be improved.

Working with a healthcare management solutions provider that lets clients maintain network and claim filing functions in-house helps control costs, and their ability to analyze historical claims data enables them to detect vision plan abuse and overpayments. Plus, their capability to eliminate unnecessary claim disbursements can assist you in managing facility and surgery costs while still providing quality vision care services to your members.

Health plans have an advantage when they are able to utilize providers that have access to the tools they need to offer a high level of service and are paid quickly. This means increased satisfaction for both the plan and provider. Similarly, when provider networks are strong and comprised of a large number of physicians from which to choose, members have more options and can select accordingly, resulting in a win-win for the plan and its members.

By opting for comprehensive solutions that encompass vision care, you have access to a full range of medical and surgical vision benefit administration services, which should include routine and medical eye care coverage, board-certified ophthalmologists, optometrists and staff, first-rate provider relationships and moderation of costs associated with all types of eye care. Such solutions integrate actionable policies based upon evidence-based medicine and preferred practice patterns to decrease comprehensive exam and diagnostic test claim costs.


Investing in managed dental care solutions driven by a large network of dental service providers results in higher network utilization, thereby providing lower costs, which can be passed on to members. According to the National Association of Dental Plans (NADP), Americans with dental benefits are more likely to go to the dentist, take their children to the dentist, receive restorative care and experience greater overall health.

A dedication to improving oral health affects not only your overall care solutions but also positively impacts the members you serve beyond just dental care. Reductions in heart disease, asthma and diabetes plus the minimization of adverse pregnancy outcomes have all been influenced by dental care.

In addition to offering a comprehensive dental care system with individualized support, your healthcare management solutions provider should be able to aid in reducing your administrative burden and helping you access information more efficiently to get paid faster.

Comprehensive and Cost-Effective Solutions

By utilizing a single partner for supplemental benefits, you are afforded a more in-depth view of your members’ overall health, allowing you to better coordinate their care to decrease spending and improve provider satisfaction. Plus, you can take advantage of data-driven and clinicallyfocused medical management processes that help maximize quality and care and achieve cost advantages. If your health plan doesn’t need multiple services or has trusted vendors for some services and is just looking for a single service to complement what is already being offered, the new partner should be flexible enough to accommodate your needs and able to easily work with any existing service providers you use.

According to Health Information Science and Systems, the potential benefits of utilizing data analytics in healthcare may include detecting diseases at earlier stages, allowing them to be treated more easily and effectively, managing specific individual and population health and detecting healthcare fraud more quickly and efficiently. It’s estimated that this process can produce more than $300 billion in savings per year in U.S. healthcare, two thirds of that through reductions of approximately eight percent in national healthcare expenditures.

The Envolve Edge

The Envolve family of health solutions is leading the way in the healthcare industry by leveraging and integrating collective expertise to deliver on the purpose of transforming the health of the community, one person at a time. Our proven results and clinical efficiencies help you meet financial targets while also providing the best-in-class care to your members for services including vision, dental, PBM, specialty pharmacy and more. By working together, our healthcare solutions help you minimize costs, improve membership growth and satisfaction, deliver a strong provider network and benefit from innovative technology solutions—through one simple, flexible partnership. Whether you need one service or multiple, Envolve works with health plans to deliver tailored, successful solutions.

By delivering benefits to the members of our health plan clients in a highly coordinated manner, our service capabilities and partnership approach provide comprehensive, whole-health management to ensure that the best possible outcomes are delivered efficiently and effectively through information-based coordinated care. We use proven processes and approaches to engage, incentivize and collaborate with our health plan clients. This results in the continual delivery of high quality, cost-effective care to their members so they receive premium services and support.

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