The Opportunities of Personalized Care in Helping High-Cost Patients Navigate the Health System Maze

October 16, 2019

Employers have limited options when it comes to traditional tools used to control health care benefits plan costs. Adjusting coverage, raising rates and changing carriers can only be done so often. However, plan sponsors and employers are under constant pressure to reduce expenses and improve benefits. As a result, many employers have put an increased focus on wellness and preventive health measures.

But in today’s world of rapidly rising healthcare costs, flu shots, walking clubs and annual physicals have become table stakes. By and large, these initiatives focus on keeping healthy individuals as healthy as they can be.

Yet in most member populations, 10 to 15 percent of the people drive between 85 and 90 percent of the healthcare costs.

These individuals interact with the healthcare system more frequently and, as a result, incur a majority of plan costs.

More and more organizations are turning to personalized care to help these members navigate the complex healthcare system maze. New human and technological resources and strategies are creating enhanced opportunities to contain costs and foster better health outcomes for these patients. Here’s a closer look at how personalized care can work for patients with chronic and catastrophic conditions.


Consider a patient who has just received a cancer diagnosis. On what may be the worst day of their lives, these patients are thrust into the health care system on a whole new level. The industry refers to this as a “catastrophic condition.” The patient starts seeing specialists and undergoing involved tests and treatments. They’re dealing with insurance issues like in- and out-of-network providers and denied claims.

How these challenges are handled can be the difference of tens of thousands of dollars for plan sponsors.

When a patient suffers from a catastrophic condition requiring a lot of medical follow-up, plan sponsors should consider providing a personal care navigator. This person, often a nurse, serves as the patient’s coordinator and quarterback throughout the healthcare process. They help schedule appointments, interpret test results and handle insurance issues that may come up.

This personalized care navigator can significantly improve cost containment, but there are numerous benefits to the patients as well.

It reduces stress and provides another medical resource to help coordinate care. Research has found it can also considerably improve health outcomes in treating the catastrophic conditions and in navigating the challenges that come with recovery1.


Other patients have increased interactions with the healthcare system as the result of a chronic condition – diabetes, hypertension, asthma, chronic obstructive pulmonary disease, etc. For these individuals, consistent and effective management of the chronic conditions is critical. Patients need to be consistent with their medication, keep their blood sugar in check, keep an inhaler nearby, and get regular breathing treatments.

Otherwise, chronic conditions can become life-threatening catastrophic conditions, putting the patient at risk while driving up costs and impacting productivity.

As a result, personalized care for these patients often focuses less on prevention and more on effective management of the condition. Emerging data warehouse tools allow employers and plan sponsors to check member conditions against treatment and medication statistics. For example, those tools can identify that a diabetic member has not had a prescription refilled or missed a recent eye exam. Then a nurse navigator or other advocate can reach out and help keep the patient on track. In most cases, patients simply got busy and forgot to take the required action. They appreciate the proactive outreach. It’s a powerful opportunity for the healthcare industry and employers to utilize big data in a meaningful way.


Personalized care is a powerful tool at plan sponsors’ disposal, but only if it’s used effectively. That starts with an analysis of member and claim data and using population health strategies to identify opportunities to reduce costs and improve care. A broker can serve as a trusted partner and benefits manager in navigating the personalized care process. Starting with the why, this partner can show the potential return on investment of a program, then work towards who the program should focus on and how it should be constructed. Often, patient navigator programs and platforms represent significant savings over traditional treatment and administrative strategies.

In many cases, savings can be at a rate of 2:1.

When done right, personalized care is a true win-win for patients and plan sponsors. There’s tremendous opportunities to use data analysis tools and strategies to cut and contain costs while offering patients a partner and a roadmap in navigating complex medical conditions. The result is a better outcome for patients and plan sponsors.

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Employee Benefits, Wellness & Population Health

Practice Leader

Joseph M. DiBella

Executive Partner, National Employee Benefits Practice Leader

More than 33 years of employee benefits experience

Previously led national and large account business for Horizon Blue Cross Blue Shield of New Jersey