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Highlights: HM Health Solutions

Closing the gaps: Designing better member outcomes

HM Health Solutions (HMHS) and its customer, a leading health insurance company in the Philadelphia region that covers more than 8 million people nationwide, joined forces to identify gaps in care for their members in the greater Philadelphia region and proactively help members close them. A "gap" is an omission, such as missed doctor visits, a lack of education about medications, or skipped preventive steps like flu shots or routine screenings.

Gaps can significantly affect an individual's health, leading to complications requiring hospitalization. In particular, patients with chronic conditions, such as cancer, diabetes, and heart disease, experience gaps in care. These gaps significantly contribute to health care costs overall. In fact, while about 30 percent of patients have chronic conditions, they account for about 70 percent of health care costs.

The health plan customer wanted a new way to reduce these gaps with its commercial and Medicare members. Medicare gives particular scrutiny to care gaps in its five-star rating system of health plans, and closing gaps in care increases star ratings. Now, to close gaps, that health plan customer is using clinical care and customer service tools that are part of the HMHS Enterprise Health Solution platform.

"The tools empower our members to take control of their health and well-being, and they equip our service team with what they need to surpass member expectations," said Nicole Gold, the health plan customer's Vice President of Operations — Customer Service and Client Setup.

The Philadelphia region health plan's customer service representatives are alerted to opportunities to discuss care gaps with members who call for other reasons. Shining the spotlight on these gaps and finding ways to close them leads to better member outcomes and ultimately lower health care costs.

Nicole Gold, health plan customer, and Brett Huberman, HM Health Solutions

Nicole Gold, health plan customer, and Brett Huberman, HM Health Solutions, use Enterprise Health Solution tools to identify and reduce gaps in patient care


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