Managing today’s disease management and wellness programs can involve the complexity of capitation, as well as the intricacy of clinical outcomes measurement. Milliman provides the insight and expertise for designing and demanding credible financial, clinical, and activity outcomes reporting for disease management and wellness programs.

Buyers—employers, health plans, state Medicaid programs, CMS—and sellers alike are becoming more critical about these programs, and Milliman is leading efforts to bring credible analysis for both purchasers and providers. Fees, risk arrangements, and projected savings should be reasonable; the savings methodology should be valid; and the outcomes reported should be credible.

Milliman actuaries and clinicians understand programs from a financial as well as clinical perspective. Our rigorous, yet practical, approach provides solutions for quantifying the value from wellness and disease management programs.

Measuring the value of services clients purchase or sell

We assisted a health plan client design a financial reconciliation methodology, which allowed optimal transparency while minimizing cumbersome reconciliation steps that added no value. Milliman actuaries performed a test of the methodology and helped make the contract language explicit—from the codes to use for identifying exclusion diagnoses, to the disease hierarchy application—down to the trend to apply to the agreed-upon claims cap. At completion, the client required its DM vendor to use this methodology for each year-end reconciliation.

Understanding which outcomes metrics make sense

Another health plan client asked us to recommend a financial savings methodology for its in-house wellness program. However, medical literature suggests the savings from this particular wellness program would require four or more years, and costs could actually increase in the interim. In addition, it would be impossible to account for all potential biases or identify a credible comparator group. We advised the client to avoid using financial outcomes, but developed an approach based on evidence-based medicine outcomes as an alternative.