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Group Overview

Member Engagement

Benefit Utilization Overview

Benefit Education Opportunities

• 🔎 Annual Wellness Visits: Only 61% of eligible members completed their no-cost exam.
• 🧠 Behavioral Health Access: Less than 45% of members flagged for risk used therapy or EAP services.
• 📱 Telehealth & Virtual Visits: 29% of members used telehealth despite full coverage and after-hours convenience.
• 🚑 ER Redirection Education: 21% of ER visits were potentially avoidable through urgent care or nurse lines.
• 🚨 ER High Flyers: 3 ER high flyers >6 visits annually do not have a care coordination team.
• 💊 Pharmacy Price Tools: Only 36% of high-cost medication users compared prices or used a copay card.
• 📦 Mail Order Pharmacy: 41% of maintenance medication users still fill prescriptions in retail settings.
• 🏥 Site-of-Service - Imaging: 38% of members used hospital-based imaging for low-cost services like MRI or X-ray.
• 🔪 Site-of-Service - Surgery: 62% of members used an Outpatient Hospital rather than an ASC for their surgery.
• 💉 Site-of-Service - Medical Injectables: 52% of members used an Outpatient Hospital rather than an office or even home setting for their injectable.
• ⚖️ Weight Management Program: Only 18% of eligible members enrolled in available lifestyle or GLP-1 support programs.
• 💉 GLP-1 Adherence: 82% of members with diabetes using GLP-1s are refill compliant.
• 📞 Care Navigation Programs: Just 22% of eligible members engaged with concierge or nurse navigator services.

Chronic Condition Opportunities

• 🩸 Diabetes – A1c Monitoring: 33% of diabetics haven’t had an A1c test in 6 months. Consider targeted nudges and virtual check-ins.
• 💊 Diabetes – GLP-1 Optimization: 16% of diabetics on GLP-1s, but many qualify and are unmanaged. Provide education + access review.
• ⚖️ Weight Management: 62% of obese members have no record of structured weight loss attempts or support program enrollment.
• 🫀 Hypertension – BP Monitoring: 27% of hypertensive members have no blood pressure recorded this year. Promote home monitoring.
• 🧠 Mental Health – Access & Follow-Up: Only 41% of members with depression diagnosis had a follow-up within 30 days.
• 🫁 Asthma/COPD – Rescue Med Usage: High SABA inhaler use without controller meds observed in 22% of chronic respiratory patients.
• 📱 Chronic Care Telehealth: Less than 18% of chronic condition members use virtual care or condition-specific health coaching.
• 🏥 Avoidable Admissions: 12% of inpatient admits for diabetes or CHF were potentially preventable with early outpatient intervention.
• 🧑‍⚕️ Care Management Enrollment: Only 9% of high-risk chronic members are actively enrolled in care management programs.

Condition-Specific ROI Modeling

• 💉 Diabetes: A1c gap closures = $410 savings/member/year | ROI: 1.7x
• ❤️ Hypertension: BP check & adherence = $300 savings/member/year | ROI: 1.6x
• ⚖️ Obesity/Weight: GLP-1/coaching = $800 savings | ROI: 2.3x
• 🧠 Mental Health: EAP/therapy access = $2,500 savings + productivity gains | ROI: 3.0x
• 💨 Asthma/COPD: Controller med use = $900 savings | ROI: 1.9x
• 🫀 CHF/CAD: Post-discharge & meds = $2,000–$3,000 savings | ROI: 2.2x
• 🧪 Hyperlipidemia: LDL checks + statin adherence = $300 savings | ROI: 1.4x

Preventive Care Gap Closure Opportunities

• 🩸 Gap Closure - A1c Testing (Diabetes): 33% of known diabetic members have not had an A1c test in the past 6 months.
• 🧬 Gap Closure - Colorectal Cancer Screening: 54% of age-eligible members have not completed a colonoscopy or Cologuard.
• 🧪 Gap Closure - Mammogram: 42% of eligible women are overdue for breast cancer screening.
• 🔍 Gap Closure - Cervical Cancer Screening: 36% of women ages 21–65 have not had a Pap test in the past 3 years.
• 🫀 Gap Closure - Blood Pressure Monitoring: 27% of hypertensive members do not have a recorded BP reading this year.
• 📅 Gap Closure - Annual Wellness Visit: 39% of eligible members have not completed their no-cost visit.
• 💊 Gap Closure - Medication Adherence: 29% of members on chronic meds have a PDC (Proportion of Days Covered) < 80%.

Rx Utilization & Adherence

Rx – GLP-1 Utilization

Rx – Specialty Utilization

Behavioral Nudges Sent

ER Usage