1

Achieving the Triple Aim

How One Health System Reduced Costs and

Improved Member Health

Executive Summary

Southcoast Health began working with consulting group Cammack Health in 2010

in an effort to control the spiraling costs of its employee health plan and improve

members’ health. Cammack Health specializes in helping health care systems

achieve the Triple Aim: improved health, better patient experience and lower costs.

Four years later, Southcoast has achieved industry-leading results.

Costs reduced – Its employee health plan has saved more than $17.2 million

compared to national trends.

Contributions stable – After increasing in nine of the previous 10 years,

employee contributions have remained the same for the last four years.

Domestic usage up – Members’ use of the system’s own facilities and

providers nearly doubled.

ER visits down – Members’ emergency room visits declined 55 percent.

Admissions down – Members’ hospital admissions declined 43 percent.

Members healthier and more engaged –

o The percentage of members participating in biometric screenings

increased 149 percent.

o The percentage of members participating in health risk assessments

increased 155 percent.

o The number of high-risk members who agreed to engage in a personal

health management program rose from 66 in 2011 to 227 in 2014.

o Members showed positive changes in regard to weight loss, smoking

cessation, glucose management, blood pressure, compliance with

routine screenings and more.

Return on investment substantial – Overall, ROI for the health management

programs was 4.2-to-1 in the most recent year.

Southcoast had an operational and strategic imperative to succeed in population

health in order to control health plan costs. Cammack Health was the ideal partner,

bringing to the engagement attributes critical to Southcoast’s achieving its goals.

Those attributes include:

Operational experience – Consultants have hands-on experience and

expertise in hospital operations and healthcare delivery.

Data-driven intelligence – Expertly analyzes data from multiple sources to

obtain vital knowledge and identify opportunities.

Grasp of root causes – Uncovers the underlying factors driving cost increases.

“We had made several

changes to plans, but we

had continued to have

double-digit cost increases

every year. Cammack

Health spoke the language

about addressing disease

management and wellness

and more actively

managing in real time the

components of the plan.

In the first four years of

this plan, we had zero

increase in our budget

related to health care,

reduced by half our

emergency room visits and

significantly increased

domestic utilization of our

services.”

David DeJesus,

Senior Vice President,

Human Resources,

Southcoast Health

2

Understanding of human behavior – Ascertains how members actually use

health services and develops creative, customized solutions.

Multifaceted approach – Achieves genuine organizational change by

addressing all elements, including plan design and governance, population

health management, stakeholder engagement and effective communication.

Achieving the Triple Aim

In 2010, Southcoast Health was struggling with challenges common to the industry

nationwide. Its self-insured employee benefit plan, then a $50 million budget line

item, had seen double-digit cost increases in nine of the previous 10 years. Medical

management offered by its insurance carrier had no effect. The plan had an

abundance of data, but no way to organize and mine it for usable information.

Employee contributions increased nearly every year.

Recognizing that radical transformation

was needed, Southcoast management

decided to partner with Cammack

Health LLC, a consulting firm

specializing in helping health systems

achieve the Triple Aim of improved

health, better patient experience and

lower costs.

Southcoast’s decision proved wise; four

years after engaging the firm, the

system’s health plan has saved more

than $17.2 million compared to national

trends (see graph, p. 8). Employee

contributions have held steady. The

health system is saving money, because

employees are increasingly using

Southcoast’s own facilities and providers. Just as important, population health

management strategies have not only decreased utilization costs, but helped

members and their families become healthier and more productive.

Cammack Health and Southcoast employed a wide range of strategies to achieve

positive results.

“To survive in today’s health

care environment, hospitals

know they must transition to

a value- based/accountable

care model, but they’re

unsure of exactly how to

accomplish it.

We identify the right path

for each client and guide

that transformation by

collaborating with them to

bring about organizational

change.”

Erin O’Connor, Esq., Partner,

Cammack Health LLC

Southcoast Health

at a Glance

Southcoast Health is a community-

based, not-for-profit health delivery

system providing a continuum of health

services in 33 communities in

southeastern Massachusetts and Rhode

Island. The system includes three

hospitals, VNA services and more than

40 medical office practices. The system

employs approximately 7,000 people. Its

self-insured health plan provides

coverage to more than 10,000

employees and dependents.

“We looked to Cammack

Health to help us save

money, improve health and

have the plan more in concert

with Southcoast’s philosophy

and mission. We’re not a for-

profit system; we’re here to

improve the health and

wellness of our

community.”

Beth Barker, Director of

Compensation and Benefits,

Southcoast Health

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New Governance Structure

Cammack Health’s experience had shown

that establishing a broad-based governing

body is critical to achieving the desired

results. Its view was—and continues to

be—that only with all the right parties

collaborating on decision-making can a

health system achieve the Triple Aim and

ensure that the employee health plan

takes into consideration the health

system’s overall population health

strategy.

With the firm’s guidance, Southcoast

established a reconfigured governance

structure. The new structure enlisted

broad internal expertise that included

physician leadership; clinicians such as

pharmacists, care managers, diabetes

educators and exercise physiologists; and

representatives from managed care, finance, marketing and other areas. The

executive committee would make the ultimate decisions, but with input from the

wellness committee and clinical advisory committee. The role of the committees was

to:

Establish expectations and set goals

Provide ongoing performance improvement review for the health plan by

reviewing the population, processes and metrics in the areas of engagement,

clinical quality and economics

Determine resources, plan design, clinical programs and other key areas to drive

results

Data Analysis Reveals Opportunities

To understand the factors driving costs and design solutions to address them, the

firm conducted a rigorous analysis of data from several sources, including medical

and pharmaceutical claims, lab values (from hospital and reference labs), biometric

screening results, health risk assessment data, provider information and more.

Cammack Health first aggregated the data into one repository. The data warehouse

then enabled Cammack Health analysts to dive deep into the data to produce

insights. Through this analysis, the team identified two main opportunities to

reduce plan costs, improve member health and provide significant return on

investment. One was to foster domestic steerage, that is, encourage members to use

About Cammack Health

New York City-based Cammack Health

provides health care and employee

benefits consulting to help clients meet

organizational goals. The firm offers plan

and program design, advanced

technology, data warehousing and

analysis, customized solutions and

ongoing support and service. Its

consultants are former senior human

resource executives in the health care

industry. They are frequent speakers at

national conferences, including those of

the Northeast Business Group on

Health, the American Society for

Healthcare Human Resources and

Healthcare Financial Management

Association.

“Involving physicians in

the governance structure

has been critical to the

health plan’s success.

Physicians bring to the

decision-making process an

invaluable clinical

perspective as well as the

ability to recommend

solutions that improve

member health and make

good economic sense.

Participation also forges a

partnership between the

physician group and the

plan that helps achieve their

common goals: keeping

patients healthy while

controlling costs.”

Michael Hyder, MD, MPH,

FACC, Chief Medical

Information Officer, Southcoast

Health; Senior Vice President

and Chief Medical Officer,

Southcoast Physicians

Network/Accountable Care

Organization

4

Southcoast’s own facilities and providers. The other was to institute a robust

population health management program.

Savings Through Domestic Steerage and Precertification

Southcoast instituted a three-tiered system that provided financial incentives for

members to utilize domestic services for inpatient, outpatient and laboratory

services – including Southcoast physicians. Most plans tier only for facilities; but

true domestic steerage starts with the providers. Members paid the least if using the

system’s own facilities and providers; standard market rates if they used a local,

partner network; and the most if they used out-of-network facilities and providers.

Concurrently, the system introduced precertification and utilization management

services through an independent third party. This allowed counselors to educate

members on the financial consequences of their choices. The interactions resulted in

significant savings, as members increasingly chose domestic services, and length of

stay and levels of service declined.

Better Health through Population Health Management

Evidence suggests that promoting good health benefits everyone—plan members,

their families, their employers and the broader community. Just as important, it

reduces health care costs, and therefore, the costs of employer-sponsored health

plans and the amount members pay in contributions and out-of-pocket fees for

services. Cammack Health and Southcoast took steps to realize these benefits by

partnering with a third-party administrator that was willing to carve out the

insurance-based medical management programs and the fees typically included in

the administrative services only (ASO) fee for the self-insured plan. These disease-

and case-management programs were replaced with a more holistic approach called

personal health management (PHM). The service is free to members who chose to

participate. It was provided by the same independent, third-party organization that

provided the precertification and utilization management functions. Under the PHM

program, the company employed local nurses to be personal health nurses (PHNs)

who worked exclusively with the Southcoast Health Plan members and providers.

The program’s goals were to:

Modify high-risk behaviors

Control chronic conditions

Manage acute conditions

Educate people to make healthy choices

Reduce costs

The consulting team fed all the previously obtained data into the data warehouse to

provide the analytics platform. The same warehouse also fed the medical

management applications that the PHNs used to find and manage patients.

“Being able to hold our

largest budget line item to no

growth in expenses frees up

money for other purposes.”

David DeJesus,

Senior Vice President,

Human Resources,

Southcoast Health

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Cammack Health used the platform to identify opportunities to optimize patient

care, engage members and providers in PHM and uncover gaps in information.

Southcoast had long offered biometric screenings and health risk assessments for

employees. However, only a small percentage of people had taken advantage of the

programs. In addition, the information collected through those programs was

provided only to the employee, so it was of limited value. At Cammack Health’s

suggestion, Southcoast increased financial incentives to encourage more members to

complete biometric screenings and health risk assessments. As a result, the number

of members completing a biometric screening increased from 1,180 in 2010 to 2,934

in 2014 and the number of members completing a health risk assessment increased

from 1,441 in 2010 to 3,678 in 2014. More importantly, the data from these

screenings and assessments were integrated into existing data to better identify

members at risk. For employees who did not have claims, this data uncovered risks

that had not been identified previously. This information was used to reduce the

unknown risk in the population.

Making Health Improvement Personal

To engage members more in their own health, Cammack Health and Southcoast

made several innovations, including launching the PHM service mentioned above

and recruiting local nurses as PHNs. The PHNs’ role was to reach out to members

at risk for health problems. They also worked closely with primary care and other

providers who cared for members. The PHM service focused on members who

were at high risk and those with an acute episode of high-intensity care. PHNs

identified the high-risk patients through risk stratification tools and predictive

modeling incorporated in the medical management technology, using all of the

available data to create the risk scores. The high-risk members the nurses contacted

were those the risk algorithms showed had complex medical conditions and were

spending five to eight times what the average member spent on health care. The

patients with acute episodes were brought to PHNs’ attention through the

precertification/utilization management service on a real-time basis. The PHNs

could start working with a member immediately upon finding out they were

planning to have a high-cost service or as soon as they got the call about an

emergency admission. They didn’t have to wait for claims to hit the system – usually

two to three months after a hospital stay.

PHNs worked with members to identify issues that were preventing them from

optimizing care, health outcomes and cost. They also integrated clinical and wellness

resources provided by Southcoast Health and/or community agencies and

coordinated with members’ providers. PHNs leveraged relationships with primary

care providers’ offices to obtain help reaching the member and getting him or her to

engage with the nurse. In 2014, the PHNs also began working with care managers

who had recently been added to the team in the Southcoast Physician Group

primary care offices.

“The best piece for

me is knowing that our

efforts are being rewarded

by improvements in

the health of our members

and their families.

The data show that

our members truly

are healthier. It’s a

positive for me, personally,

that we’ve been able to

impact people’s lives.”

Beth Barker, Director of

Compensation and Benefits,

Southcoast Health

6

The PHNs made a significant difference. In 2010, member engagement in the health

insurance company’s disease-management program had been approximately 20

percent. By contrast, the PHNs were able to engage 76 percent of the members they

were able to reach. This was even more impressive because the definition of

engagement was stricter under the PHM program, requiring not just a telephone

call, but an ongoing relationship between the nurse and the member.

By the end of the program’s first year, members participating in PHM had a higher

compliance rate with key evidence-based metrics than those who qualified for the

service but did not engage. Those metrics included regular HbA1c tests for diabetes

patients and LDL cholesterol tests for diabetes and coronary artery disease patients.

These results have continued in the subsequent years.

Addressing Threats to Health

The medical community recognizes that certain conditions and lifestyle choices are

highly likely to result in complex health issues if not addressed. Obesity is one

example. Obesity was found to be a substantial risk factor for members, as it is in

the general population. The health and productivity problems associated with

obesity are well known. Cammack Health worked with Southcoast to adapt an

existing weight management program into a more comprehensive service for

members and provide financial incentives for participation. The initial 106 members

who enrolled in the program lost an average of 17.8 pounds per person in the first

year, with eight people losing more than 50 pounds each. Using this experience,

Southcoast expanded the outreach to engage at-risk members through an early-

intervention program. Southcoast’s Diabetes Management Program also wanted to

offer a Diabetes Prevention Program, having recently hired someone who had run a

successful program elsewhere. Cammack Health worked with the Southcoast

Diabetes Education team to develop a program that could be offered specifically to

employees who were obese or overweight and pre-diabetic. On an overall basis, the

employees who had their BMI tested during biometric screening in two consecutive

years saw a slight decrease in people who were overweight.

Cammack Health created a special risk stratification protocol to identify members

whose biometric screenings or health risk assessments showed they were at risk of

developing chronic disease in the future. These included people who were

overweight or obese or showed signs of incipient diabetes, hypertension or high

cholesterol. Southcoast’s wellness coordinator, acting in the role of health coach,

reached out to engage these members, steering them to Southcoast-sponsored

Weight Management and Diabetes Prevention programs to reduce health risks.

The system also introduced the Virgin Pulse online wellness platform, including on-

site health stations for screening blood pressures and measuring body mass.

Southcoast also ramped up on-site wellness initiatives by offering healthy cafeteria

choices, yoga, stress management and tobacco-cessation programs. Often, the

system offered discounts and other financial incentives to encourage member

participation.

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Communicating Effectively

Throughout the planning and

implementation of these and other

innovations, the consulting team and

Southcoast’s internal marketing

experts worked together to conduct

communications campaigns to keep

members, physicians and other

stakeholders informed about changes

and explain how those changes would

benefit them. In addition to creating

written communications, the firm

arranged for personal

communications and face-to-face

meetings. For example, physicians

serving on the plan’s governing board

were asked to telephone physician

colleagues to let them know about

upcoming medical management

initiatives and suggest they take part.

The firm also used a continuous

improvement process, meeting

regularly with the client’s core team

to evaluate progress and ensure the

project was moving forward as

planned.

Member Satisfaction

Southcoast Health Plan was eager to understand how members felt about their

experience with the plan, the PHNs and their providers. Cammack Health created

and managed an online member survey to assess several key aspects of members’

experience. The survey included questions, based on the HCAHPS (Hospital

Consumer Assessment of Healthcare Providers and Systems) instrument, about

their experience with their primary care provider. Approximately one-third of the

employees covered by the plan participated in the initial survey. In most areas,

members rated their experience as very good or good 80 to 90 percent of the time.

Ninety-seven percent said they would recommend their primary care provider to

their friends or family, and 95 percent said they would recommend their personal

health nurse.

Solving the Real Problem

A Southcoast Health Plan member with

diabetes had an inpatient admission,

including a stay in the ICU, due to poorly

regulated blood glucose levels. The

Personal Health Nurse found that the

person needed an insulin pump to properly

regulate his blood sugar, but that the plan’s

deductible made the equipment

unaffordable for him. In reality, the

impatient stay wound up costing the plan

far more than the pump would.

The solution: provide the member (and

others) with the pump at no charge to

improve his health while reducing the

financial burden on the plan. The

recommendation was approved by the

Clinical Advisory Council for the Health

Plan and adopted by the Executive

Committee. “This is an example of what

makes us different from conventional

benefits consulting firms,” says Cammack

Health Partner Erin O’Connor. “We find the

root causes of high costs and then address

the human factors behind them.”

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Industry-Leading Results

The results of innovations described here can be seen in the illustrations below. The

data demonstrate that the decisive changes Cammack Health and Southcoast

implemented had a powerful, positive impact on the health of the plan and the

people covered under it.

Southcoast’s cost of care trend outperforms national projections. The

system has saved more than $17M compared to trend since partnering

with Cammack Health.

Medical Management Savings and Return on Investment: 2014

Service Type Cost $ Saved ROI

Utilization Review $372,888 $1,422,707 3.82

Personal Health Management $280,191 $2,103,880 7.51

Total $653,079 $3,526,587 5.40

Last year alone, Southcoast earned a return on investment of 5.40.

$443

$478

$519

$558

$594

$443$432

$445 $441

$481

$300

$350

$400

$450

$500

$550

$600

$650

2010 2011 2012 2013 2014

AHIP Projected Trend

Southcoast Actual Trend

9

Domestic Utilization % of Services

The percentage of claims utilizing domestic services rose 20 percentage

points after Cammack Health’s recommendations were implemented.

Emergency Room Visits / 1000

The number of emergency room visits was more than cut in half.

20%

32%

36%38%

40%

0%

10%

20%

30%

40%

50%

2010 2011 2012 2013 2014

483

211 208237 222

0

100

200

300

400

500

600

2010 2011 2012 2013 2014

10

Admissions per 1,000 Members

The number of hospital admissions declined by 40 percent.

Biometric Screenings and Health Risk Assessments

95

68 65

56 57

0

20

40

60

80

100

2010 2011 2012 2013 2014

1,1801,299

2,016

2,982 2,934

1,441 1,425

2,617

3,265

3,678

0

1,000

2,000

3,000

4,000

2010 2011 2012 2013 2014

Biometric Screenings

Health Risk Assessments

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Members are gaining insights that can help them stay healthy. The

percentage of members participating in biometric screenings and health

risk assessments has increased.

Engagement in Personal Health Management

Members are taking greater responsibility for their own health. The

percentage of high-risk members participating in personal health

management programs has increased.

Compliance with Health Screenings

The percentage of members screened for health risk has climbed steadily

over the last three years.

66

133

258

226

0

50

100

150

200

250

300

2011 2012 2013 2014

90%

75%

88% 88%

80%

88%86% 85%82% 84%

53%

61%

40%

50%

60%

70%

80%

90%

100%

Q4 2011 Q4 2012 Q4 2013 Q4 2014

CAD LDL Testing Compliance

Cervical Cancer Screening

Diabetes 1 HbA1c TestCompliance

Mammogram

Diabetes LDL Testing Compliance

Diabetes NephropathyCompliance

Colorectal Cancer Screening

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Conclusion

Thorough a very methodical approach, Southcoast Health was able to keep its

healthcare costs nearly flat. In the plan years 2011–2014, Southcoast did not raise

employee contributions. They implemented a wellness incentive that more than

two-thirds of their employees were able to achieve. More importantly, the data from

screenings was actually put into use to help people address rising health risks.

In addition to keeping contributions flat, Southcoast did not achieve savings by

drastic changes to co-pays and deductibles. They maintained market competitive

plan design. By creating a plan tier of its own physicians, Southcoast helped direct

members to high quality and lower cost providers: Southcoast providers consistently

outperformed the health plan network as a whole on Evidence Based Measures

(EBMs). In addition, the Health Plan Member Experience survey (conducted bi-

annually) demonstrated member satisfaction with their PCP at 92%.

Overall, no cost-shifting, satisfied members, increased domestic capture, flat trend,

and improved health sustained over a four-year period are all evidence that

Southcoast Health Plan has delivered on the strategy outlined at the start of the

engagement with Cammack Health.

For Additional Information

To learn more about Cammack Health, contact Erin O’Connor, partner, at 212-227-

7770 ext. 228 or eoconnor@cammackhealth.com.

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Erin M. O'Connor, Esq., Partner

Erin joined Cammack Health (formerly Cammack LaRhette) in 2004 as a member

of the executive team. As a leader in the Accountable Solutions area, Erin develops

strategic partnerships with clients who migrating to population health management.

She works with industry leaders, clients and partners to develop best practices for

accountable care.

Key areas of Erin's expertise are organizational development, engagement, and

change management. She has developed engagement and communications programs

targeting physicians, organizational leadership and employees. Erin excels at creating

and embedding processes to overcome barriers to change. She is currently leading

engagements to integrate health and productivity management in several health care

systems in the Northeast.

Erin has 25 years of experience in human resources and health care operations.

Prior to joining Cammack Health, she was the chief HR executive at two large

health care organizations, one of which operated several health plans.

She is a graduate of Cornell University's School of Industrial and Labor Relations

and Fordham University School of Law.

212.227.7770 x228

eoconnor@cammackhealth.com

“Employers are

frustrated with off-the-

shelf ‘wellness’

programs that don’t

make a difference.

With our depth of

experience in population

health management, we’re

able to help clients

develop programs that are

game changers—

innovations that will

actually change

outcomes.”