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Cost breakthroughs in complex care management

Not every complex care management program is built equally. Here's how to optimize them for maximum benefits.

4-minute read

The arrival of complex care management (CCM) has been of enormous importance and benefit to thousands of high-need, high-complexity patients. CCM programs are now in place in every state in the nation.1 Given their highly strategic aims and extensive adoption, they should be the silver bullet the industry has long waited for. Having a CCM program in place can help reduce hospital admissions and stays, decrease total health care spend per patient and curtail specialist visits.2

But member participation is sometimes as low as 13% for those targeted for the program.3 And while payers spend as much as 10% of their administrative budgets on care management, they’re rarely seeing a decent ROI.4 A McKinsey report indicated a dire need to “reset the vision for payer care management.” A shift of CCM toward a payer-led effort to treat the whole person, often at sites that are easier for members to access, can help. In other words, to make CCM truly work, payers must do more to meet members where they are. They also must adopt the digital advancements and data analytics strategies that promise to bring CCM closer to its ultimate potential. Here’s how to set that process in motion.

Strategy 1: Rethink your member engagement approach

Often, CCM programs center around a team of specialized nurses who monitor members’ health and well-being and coordinate care on their behalf. And while these dedicated workers are crucial to the success of any CCM program, their efforts cannot exist in a vacuum. Further engagement is required to:

  • Solidify member education about their conditions 
  • Encourage care plan adherence 
  • Activate CCM participation in members who’d benefit most from these services

According to one report, up to 80% of members whose conditions would best be served by a CCM program are never identified or enrolled. This can leave a staggering 90% of a program’s potential value unrealized.5

How can this be improved? First by diversifying a program’s outreach beyond phone calls, which often fail to reach members at all, thanks to outdated or erroneous information. For example, one payer was missing 60% of its members’ correct contact information.6 That’s why it’s necessary to have an array of contact quivers in the program’s bow, including:

  • Text messaging 
  • An email module 
  • A print mail program 
  • Video conferencing 
  • The ability to perform in-person house calls

While 80% of health care consumers say they prefer digital engagement methods,7 there’s more to be gained from incorporating nondigital modes of communication than from ignoring them.

It's also important that members understand the potential benefits they can access if they adhere to the CCM program. Opening the initial conversation with nudges to address health conditions or improve habits won’t land if they’re not balanced with a clear explanation of how care management can help the member. Once members have invested time and energy into the program and their trust has been earned, a payer’s health coaching is likely to be far better received.

Strategy 2: Take a data-based approach — both digital and human — to easing administrative burden

Digital automation has come a long way — and can make all the difference, particularly when used for non-member-facing tasks. Data-driven algorithms can be trained to automatically evaluate cases, determine their relative urgency, and assign them to an appropriate case manager based on caseload, experience level or specialty. That alone has the potential to streamline case management and ensure that staff time and energy are being allocated appropriately.

Further, data analytics can be a game-changer for predicting patients most likely to experience future hospitalizations, the most likely medical outcome and how to head off worst-case scenarios with preventive care strategies. These data-driven interventions can change the course of a patient’s condition for the better, eliminating costly hospital admissions or unplanned treatment needs.

Of course, the human touch still makes a big difference, too. A targeted claims review process that deploys dedicated physician reviewers to pore over complex claims can dramatically reduce costs. Armed with extensive clinical experience no algorithm can replicate, these trained professionals comb through procedural and surgical claims to find errors and irregularities. And find them they do: The physician reviewers in the Optum® Focused Claims Review program identify errors in 60% to 75% of the claims they investigate. As a result, they help clients save anywhere from 14% to 28% of the dollar amounts reviewed in these claims.8

Strategy 3: Institute metrics to continuously gauge and improve program performance

It’s not enough to look solely at revenue versus overhead or total number of emergency department visits per year. Your quality metrics need to pay close attention to multiple aspects of your CCM program’s operations, such as:9

  • Level of administrative burden relative to member participation 
  • Rate of utilization among members targeted for inclusion 
  • Rate of medication adherence among members enrolled 
  • Rate of care recommendation follow-through after contact with program administrators 
  • Decrease or increase in hospital admissions or readmissions 
  • Anecdotal reports and responses from patients, providers, staff and other stakeholders 

Only by taking a 360-degree view of your program’s strengths and shortcomings can you identify areas to address.

Of course, these suggestions are just the beginning. Ideally, your program will apply advanced data analytics to all quantitative aspects of operations that can be improved with greater insight. Experimenting with various member-focused engagements and prioritizing back-end digitalization and expert-driven claims review can also help optimize performance and reach those in need. Get these foundational methodologies in place, and your CCM program will be in a far better position to aid those who need it most.

Learn about Optum complex care solutions for Transplant and Kidney Disease Management and how Focused Claims Review can help ensure billing accuracy of professional and facility claims.


  1. Better Care Playbook. Map of complex care sites in the U.S. Accessed June 9, 2023.
  2. Powers BW, Modarai F, Palakodeti S, et al. Impact of complex care management on spending and utilization for high-need, high-cost Medicaid patients. AJMC. 2020;26(2):e57–e63.
  3. McKinsey & Co. Supercharging the ROI of your care management programs. Accessed June 9, 2023.
  4. McKinsey & Co. The untapped potential of payer care management. Accessed June 9, 2023.
  5. McKinsey & Co. Supercharging the ROI of your care management programs. Accessed June 9, 2023.
  6. McKinsey & Co. The untapped potential of payer care management. Accessed June 9, 2023.
  7. Business Wire. 80% of patients prefer to use digital communication to interact with healthcare providers and brands. Accessed June 9, 2023.
  8. Optum. Focused Claims Review for Health Plans. Accessed June 9, 2023.
  9. Camden Coalition. Complex care startup toolkit. Accessed June 9, 2023.