THE STATE OF UTILIZATION

MANAGEMENT, CARE
MANAGEMENT, AND
POPULATION HEALTH
IN 2024
What do health plans need next?
A fundamental transformation is required
to better extract insights from broader data
sets to drive efficiencies in and enhance the
value of their utilization management, care
management, and population health
management programs.

1
 TABLE OF CONTENTS
Introduction 3

Key Findings 4

The State of Utilization Management 5

The State of Care Management 8

Tackling the Staffing Crisis: A Blend of Tech Advances 11

and Process Reengineering

What Health Plans Need to Transform Utilization 12

Management and Care Management

Contextual Awareness and Personalized Member 14

Experiences: Impact at the Health Inflection Point

Digital Care Management: Driving Efficiencies to Reach 17

More Members

Data and Data Management: Time to be Strategic 19

Regulatory Readiness: How Care Management, 23

Utilization Management, and Data Integration Support
Current and Future Compliance

Conclusion 25

Sources & Methodology 26

2
 INTRODUCTION
Health plan leaders are currently facing a triad of formidable challenges: operating CM programs can improve the healthcare experience and
the relentless 7% increase in medical costs projected for 2024, up from generate a 2:1 ROI.4 Improvements will undoubtedly extend into utilization
5.5% and 6.0% in 2022 and 2023, respectively;1 skyrocketing costs of management and population health management (PHM) as well.
healthcare administration that represent about 30% of excess U.S. health
spending;2 and the ongoing workforce challenges, which more than one- Today’s health plan leaders consider legacy solutions, strategies,
third (37%) of health plan executives say will impact their strategy in 2024.3 and workflows for CM, UM, and PHM programs as only moderately
effective, indicating an opportunity to significantly improve the results
Amid those conditions, many health plans are doubling down on and of these programs with cutting-edge tools. Automating processes and
reassessing their care management (CM), utilization management (UM), administrative tasks can save health plans an estimated $187 billion
and personalized member engagement strategies to combat rising costs annually,5 up from $122 billion in 2021.6 But health plans need the data,
and ease administrative burden while ensuring their members receive the analytics, AI, automation, and workflow technology to better manage
most appropriate and effective medical care possible. While seemingly utilization and to achieve the personalization necessary for sustaining
focused on different end results, CM and UM teams share common goals member engagement to reduce costs and improve health outcomes.
– to provide the right care to the member at the right time, avoiding
unnecessary utilization and improving health outcomes and quality of
life for their members. Both teams are facing the need to manage a Both the urgent need and opportunities are clear – but are
growing influx of data sources that should help them more quickly assess health plans ready to undertake that transformation?
the needs of members and accelerate both decision making and access
to the necessary care. Leveraging these data sets is manual at best and
impossible at worst. Adding to the data complexities is the ongoing To learn from health plan leaders and gain a better understanding of
talent crisis forcing plans to do more with less as they navigate the the current state of care management, utilization management, and
waters of ensuring optimal member health while minimizing waste and population health management, Medecision commissioned healthcare
overutilization. consultancy Sage Growth Partners to conduct independent research.
The survey included 53 respondents, spanning CEOs, CIOs, Chief
What health plans need now is a way to transform their UM, CM, and Medical Officers, Chiefs of Population Health, and VPs from at least 24
engagement capabilities to drive impact at the health inflection point. unique organizations. Participants represent a range of functions: care
Leveraging new technologies that enable strategic use of data to speed management, care coordination, utilization management, and operations.
decision making, deliver a level of personalization that encourages trust Survey respondents were screened to ensure familiarity with their
from members, and reaches more members in need of services, will organization’s approach to CM, UM, and PHM.
enable health plans to drive down administrative, operational, and medical
costs, improve efficiencies, and decrease staff burden. Thinking about care
management alone, McKinsey estimates that health plans successfully

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 KEY FINDINGS

100% Yet, half (49%)

of surveyed health plan leaders believe there is say their health plan accommodates fewer
value in having contextual awareness about their than 40% of rising-risk members, and 36% of
members’ health journeys respondents currently accommodate fewer than
40% of high-risk members

95% 68%
say it is “moderately important” or “very important”
to incorporate personalization into care say inefficient workflows are the top frustration
management, but only 34% rate their health plan with their current utilization management tools,
as “very personalized” and 49% say high costs associated with data
fragmentation are a top frustration

77%
of survey respondents say it is “very important” 63%
to see all touch points for high-risk members, of survey respondents find great value in care
and 60% say it is “very important” for rising-risk management and coordination tools in preparing
members to be able to comply with existing and future
regulations

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

THE STATE OF UTILIZATION MANAGEMENT

Health plans need real-time access to all the data required to manage Strategically leveraging multiple data types and sources to enhance
utilization across their member populations, but survey respondents say utilization management decisions will dramatically streamline processes,
legacy tools render UM programs only “moderately effective.” Just one- drive greater efficiencies, reduce delays, and result in better outcomes
third say the tools are “very effective” for having all of the data necessary while reducing costs. But can health plans really access that data quickly
for timely review and approval, and fewer than one-third rate them as enough with today’s technology tools and data sets? Not likely. As a result,
“very effective,” meaning there is room for improvement when it comes integrating accurate, high-quality, and sufficient data in a timely fashion
to identifying health events in time to impact utilization of services and challenges the UM and CM teams’ ability to impact member health truly at
minimize provider abrasion. Given the critical role utilization management the inflection point.
plays in the ability for health plans to succeed, these moderately effective
programs have to be improved with cutting-edge technologies. Room for Improvement: Legacy UM Programs
When asked about current utilization management solutions,
leaders say:

77%
68%
64%

51%

HEALTH PLANS CAN IMPROVE 42%

32%
25%
UTILIZATION MANAGEMENT BY 8%
4%
8%
19%
4%

INTEGRATING A WIDER VARIETY OF Turnaround time Having all the data Identifying health Minimizing provider
necessary for timely events in time to abrasion
DATA TYPES — MEDICAL, SOCIAL, review and approval impact utilizations
services
BEHAVIORAL, AND GENETIC, AMONG
VERY EFFECTIVE MODERATELY EFFECTIVE NOT EFFECTIVE
OTHERS — TO DRIVE EFFICIENCIES,
REDUCE COSTS, AND IMPROVE Part of the reason UM tools are ineffective is because most are not that
easy to use. In fact, survey respondents say only about one-quarter of the
MEMBER EXPERIENCE. tools for each of the various functions are “easy” to use.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Reality Check: Legacy Utilization Management Tools This research shows that, in general, the UM process lacks automation.
This lack of automation inhibits the ability for UM teams to be effective
When asked about how easy it is to use today’s UM tools, and undoubtedly results in heavier than necessary workloads, longer
leaders say: turnaround times, and higher than necessary medical spend.

Add reviewer in the chain of command for escalation or review Exacerbating the challenges caused by lack of automation is the
inadequate integration of data needed to perform tasks, even manually,
28% 62% 9%
which limits the UM team’s ability to be effective. When asked about
barriers to the tools currently being used in UM processes, more than
Use of ADT files
half of health plan leaders say that data is fragmented and not integrated
26% 60% 13% into workflows, and that data integration is burdensome. As a result,
survey respondents say their organization is frustrated by inefficient
Automation of approvals workflows, the expenses associated with data silos, and provider abrasion.

26% 62% 11%

Automation to handle peer to peer scheduling

Leading-edge
23% 58% 19%
tools for utilization
Automation to requests from faxes
management will improve
21% 57% 23%

outcomes for patients,

Understanding workload balancing of clinicians and medical directors

15% 72% 13%

prevent unnecessary
Managing staff workloads
hospitalizations, and
13% 74% 13% reduce avoidable
high-risk events.
EASY SOMEWHAT DIFFICULT DIFFICULT

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Fragmented and Not Integrated: Legacy Utilization Leaders list their frustrations due to the barriers with current
Management Programs UM tools as:

Leaders say the barriers to current UM tools include: Inefficient workflows

68%
Data is fragmented
High costs associated with data inaccessibility, fragmentation, silos
57%
49%
Data doesn’t currently flow into workflows
Provider abrasion
55%
40%
Data integration is burdensome
Staff complaints
55%
38%
Data is siloed
Member complaints
51%
26%
Software is cumbersome
Lack of coverage across member base
32%
17%
Ease of use of the tool
28%
This research shows that today’s tools and practices are frustrating,
Lack of data transformation interoperability is lacking, and health plans are struggling to strategically
26% leverage their data for utilization management purposes.

Data is inaccessible
15%

57% OF HEALTH PLAN LEADERS SAY

FRAGMENTED DATA AND THE LACK OF
INTEGRATION ARE TOP BARRIERS TO
EFFECTIVE UTILIZATION MANAGEMENT.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

THE STATE OF CARE MANAGEMENT

All participating health plan leaders say it is important to create holistic When asked about their current member or patient base,
views of where members are on their individual health journeys to create respondents were able to accommodate care management
truly meaningful care plans for members. or coordination services in the following risk profiles:

When asked about the importance of a holistic view of members

Low-Risk Members
on their care journey, plans agree this is important:
8% 30%
LESS THAN 20%

21-40%

17% 41-60%

79% 21% 61-80%

> 80%

Very Important Moderately Important 23% 23%

Rising-Risk Members

2% 13%
But as they indicated, regarding utilization management tools, today’s care
management technologies, strategies, and workflows pose challenges for 13%
health plans looking to expand their programs. In fact, despite investing
as much as 10% of their administrative spend on CM,7 more than one-
third of survey respondents claim they accommodate fewer than 40% 36% 36%
of expensive high-risk members in their CM programs. Half say they
engage fewer than 40% of rising-risk members as well – accommodating
these individuals is critical to improving health outcomes and avoiding High-Risk Members
unnecessary costs down the road.
9%
19%
11% 25%
36%
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

The biggest barriers to reaching more members in CM programs include All of the aforementioned conditions render many health plans unable to
lack of member engagement tools, no member personalization, and the expand CM programs – which negatively impacts both clinical outcomes
inability to react or respond to members in time to make an impact at the for individuals and member populations and health plans’ financials.
health inflection point.
Care Management Pain Points
Survey respondents rate the technologies and tools they use for CM as Aside from documenting a care plan, care management teams
only “moderately effective,” making the problem of low engagement
struggle with the usability of current care management technology
rates more difficult. This suggests implementing updated technology that
provides agility, flexibility, and quicker access to data would significantly DIFFICULT/
enhance CM results. Health plan leaders say that creating workflows EASY MODERATELY DIFFICULT

based on member preferences or member criteria, digital member Have members self-schedule with care manager 11% 89%
assessments, self-scheduling, and enabling members to manage their
Have members manage their own care goals 17% 83%
own care and goals are among the top pain points.
Communicate with members via text 17% 83%

Improve member outcomes by automating next 19% 81%

The biggest barriers to member participation in care best actions

management programs Create workflows based on member preferences 21% 79%

Lack of member engagement tools Integrate the care plan with community-based 21% 79%
services criteria
51%
Have a member complete an assessment digitally 21% 79%
Lack of personalization for members
Create workflows based on user preferences 23% 77%
40%
Create workflows based on member criteria 23% 77%
Lack of ability to react in real time
See all touch points between care management 25% 75%
40% team and member

Too much lag between health event and our ability to intervene Complete periodic digital check-ins between 25% 75%
member and care manager
40%
Develop bespoke member populations based on 25% 75%
Lack of member self-service tools clinical, SDoH or other indicators
28%
Bi-directionally communicate with members 25% 75%
Lack of visibility to member health journeys Collect member-reported outcomes 25% 75%
26%
Change the care plan for a member and send 26% 74%
information digitally

Communicate with members via email 28% 72%

Document a care plan 40% 60%

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

When asked about how effective existing solutions are in affecting care Thinking about care management, how effective
management workflows, respondents agreed that today’s solutions are are your solutions, strategies, and workflows in
insufficient for increasing member engagement, automating campaigns,
affecting each of the following?
decreasing the cost of care, and providing visibility to the member’s entire
care journey — all of which are critical to driving results with care management Increased members targeted for intervention
programs. 47%
51%
Are Moderately Effective Care Management Tools 2%

Really Good Enough? Improved member outcomes

43%
When asked how effective current solutions, strategies, and workflow 53%
are in affecting each of the following, health plan leaders say the tools 4%

are largely just “moderately effective” rather than “highly effective.” Reduce unnecessary utilization of services
36%
57%
8%

The implications of not Increased member engagement with services

30%
reaching more members 68%
2%

include poorer health Providing automated campaigns to reach all members effectively
26%
outcomes for the members, 64%
9%

higher cost trends for the Decreased cost of care

23%
plan, and poorer quality 68%
9%

results overall. Providing visibility to all of the touch points between care management
and members across the member’s care journey
19%
74%
8%

VERY EFFECTIVE MODERATELY EFFECTIVE NOT EFFECTIVE

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 THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

TACKLING THE STAFFING CRISIS:

A Blend of Tech Advances and Process Reengineering
Legacy technology and lack of data strategy may limit the ability of health
plans to increase their reach in care management functions and improve
their efficiency, speed, and effectiveness with utilization management
efforts; however, health plan leaders say member participation or
compliance and staffing limitations are even greater barriers to success. SURVEY RESPONDENTS SAY LACKING
By improving technology and automation, increasing the effective IT SUPPORT AND RESOURCES ARE
use of digital CM campaigns, and enhancing the strategic use of data,
existing teams can reach more members and overcome some of the
AMONG THE REASONS THEIR HEALTH
barriers staffing limitations impose. Automation, AI, and machine learning HAS NOT EFFECTIVELY INTEGRATED
advancements will be critical to enabling health plans to accelerate
utilization management decisions and ease the administrative burden on A WIDER RANGE OF DATA TYPES INTO
their workforce. UTILIZATION MANAGEMENT AND CARE
What is the most significant barrier to expanding MANAGEMENT WORKFLOWS.
care management or coordination coverage to more
members?

38% 34%
8%
17% 2%

Member Staffing Lack of data or Provider Identification of

participation or limitations insights about abrasion or members needing
compliance members’ health reluctance services
events

[ Other: 1% }
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

WHAT HEALTH PLANS NEED TO TRANSFORM

UTILIZATION MANAGEMENT AND CARE MANAGEMENT
As the data shows in the previous sections, health plan leaders say it is Where Today’s Tools Work — and Where They Fall Short
important to both create holistic views into member health journeys
and to establish visibility into all touchpoints with members along the way. We asked survey respondents how well their current solutions
However, survey respondents are generally dissatisfied with current solutions. allow their organization to perform the following:
NOT
None of the existing tools were rated as serving their needs “very well” VERY WELL VERY WELL
by more than 28% of respondents. Perhaps the most striking finding is Have all the data available to see improvement toward health goals 28% 72%
that while the vast majority of leaders who identified personalization and of members

having full contextual awareness of members as key drivers of improved Ensure timely and personalized interventions, maximizing each 26% 73%
care management functions, fewer than one-quarter do this very well interaction’s impact

today, and more than one-quarter aren’t able to do this well at all. Process data to find patterns, and help build risk stratification models 26% 73%

Provide the 360-degree view of where a member is their care journey 26% 74%
Although emails and texts are commonly used digital solutions, survey
Process vast amounts of data, revealing patterns, and insights with 23% 77%
respondents say they are not impactful at driving improved outcomes. predictive modeling, risk stratification, and trend analysis
Additionally, current solutions do not empower users to design
Enable targeted approaches tailored to individual needs and characteristics 21% 79%
personalized email and text templates. Over one-third (38%) of health
plan leaders say current AI and machine learning tools are not sufficient Empower users to design personalized email and text templates 21% 79%

for optimizing workflows to increase engagement, suggesting today’s Have visibility into member participation with their care 21% 79%
tools are long overdue for an upgrade. Looking toward the future, 51% Provide the data available to see the members journey and adherence to 21% 79%
are optimistic that AI and machine learning would be “very impactful” in care plan
optimizing workflows to increase member engagement and outcomes. Identify the next best action for rising risk members 21% 79%

Have real-time dashboarding and reporting to assess member and 21% 79%
Cutting-edge technology upgrades can also improve efficiencies in population or cohort health
the utilization management functions, helping to not only drive down
Identify the next best action for low-risk members 19% 81%
costs but also reduce provider abrasion, streamline processes, and
create efficiencies that improve the member experience. With half of Create interactive care journeys with assessments and personalized content 17% 83%

the respondents saying they can perform most of their CM and UM Identify the next best action for high-risk members 17% 83%
functions only “moderately well,” leaders have to consider how improved Machine learning and AI tools to optimize workflows to increase member 15% 85%
technology can accelerate outcomes for plans and their member base, engagement and health outcomes
enabling key capabilities across the functions. Create omni-channel campaigns for broader health plan/provider offerings 15% 85%
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

The chart clearly demonstrates that survey respondents report limitations What Health Plans Need to Improve Health Outcomes
in using and accessing data to effectively optimize their CM and UM
functions. Further probing on the adequacy of the data they do have Survey respondents say the following would be impactful in driving
suggests concerns with the quality of that data as well. Respondents better care management outcomes for their member population:
largely categorized the state of data availability as “somewhat adequate”
Build targeted approaches on a population level, tailored to individual needs
at 62%, indicating some frustrations with their current solutions. Only 26%
and characteristics
say their data availability is “completely adequate.” Given the power timely
53% 43% 4%
access to high-quality data sets can have in aiding contextual awareness
and the full patient journey, health plans require better solutions. Process vast amounts of data to find patterns and insights with predictive modeling,
risk stratification, and trend analysis

When asked to rate the adequacy of member data 53% 47%

availability through digital care management tools Build personalized rules based on data, to create timely and personalized interventions

for supporting healthcare decision making and 51% 49%

member care, survey respondents said: Optimize workflows with machine learning and AI to increase member engagement
and health outcomes

51% 40% 9%

26% 62% 11% Create interactive care journeys with assessments and personalized content

47% 49% 4%
Very Important Moderately Not Adequate
Design personalized email and text templates
Important
38% 55% 8%

Data types include: ADT, claims, pharmacy, labs, Create omni-channel campaigns for health plan/provider offerings
member-reported, fitness tracker, remote monitoring
38% 58% 4%

VERY IMPACTFUL SOMEWHAT IMPACTFUL NOT IMPACTFUL

Recognizing that health plans were considering their legacy technology
solutions for CM, UM, and PHM when surveyed, researchers probed
into how they could achieve better outcomes. More than half of survey While much of the data outlined above is specific to CM, the overall research
respondents say the most impactful tools to drive better outcomes relate supports the notion that to drive improved efficiency across UM, CM, and
to personalization, trend identification, and predictive modeling. They PHM, plans should focus on strategically using data across those functions.
are optimistic that AI and machine learning would be very impactful
at optimizing workflows to increase engagement and outcomes (even To enhance adherence to the plan, it’s crucial to present information in a
though, as we noted earlier, current solutions do not yet do this well). manner that is comprehensible and actionable for members. This demands
the implementation of tailored programs and tools designed to ensure
members fully benefit from their designated level of care.
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

CONTEXTUAL AWARENESS AND

PERSONALIZED MEMBER EXPERIENCES:
Impact at the Health Inflection Point
Care management and utilization management teams are working Health plans that establish personalized, contextually aware views into
hard to impact member health longitudinally and on an episodic member health journeys — informed by all available and relevant data
basis, while at the same time striving to minimize unnecessary — can achieve maximum impact with digital CM, traditional/telephonic/
medical spend. day-to-day CM, UM, and PHM programs. But despite the survey findings
showing that most health plan leaders understand that reality, only about
With effective utilization management tools being necessary for both one-third say their organization’s program is “very personalized.”
traditional care management functions as well as core utilization
management efforts and workflows, the technology platform driving UM
is critical. Modern utilization management tools provide the contextual
awareness of a member’s health journey, which enables better informed
and faster decision making, and drives efficiencies, reduces provider
abrasion, and increases member satisfaction and trust. Incorporating
personalization into care management workflows enables health plans
NEARLY 100% OF HEALTH PLAN
to improve outcomes by reaching members at the health inflection LEADERS SAY INCORPORATING
point when it matters most, not 90 days after a health event.
PERSONALIZATION INTO UM, CM,
PHM, AND DIGITAL CARE MANAGEMENT
IS IMPORTANT.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

How important is it to incorporate personalization into Please rate the level of personalization in the following
the following functions and workflows? functions and workflows today

60% 62%
55% 55% 58%
51% 55%
43% 45%
38% 40%
34%
25%
6% 4% 21%
2% 2% 17% 17%
11%

Digital Care Day-to-Day Care Utilization Population Health

Care Management Utilization Population Health
Management Management Management Management
Management Management

VERY IMPORTANT MODERATELY IMPORTANT NOT IMPORTANT

This research shows that personalization can have a “high impact” or a
“moderate impact” across the CM, UM, and PHM functions including
creating custom care plans and journeys for members, establishing member
trust in their care, reducing unnecessary utilization and cost, and driving better
health outcomes.

INCORPORATING PERSONALIZATION
INTO WORKFLOWS CAN HAVE A
SIGNIFICANT IMPACT ON IMPROVING
OUTCOMES, ENGAGING MEMBERS,
AND REDUCING COSTS, BUT FEW
RATE THEIR HEALTH PLAN AS VERY
PERSONALIZED.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Personalization can drive positive impacts across care management, utilization

management, and population health management

HIGH MODERATE LOW HIGH MODERATE LOW

IMPACT IMPACT IMPACT IMPACT IMPACT IMPACT

Utilization Management Population Health Management

Reducing Unnecessary 60% 37% 4% Improve Member 62% 36% 2%

Utilization Participation

Reducing Provider Abrasion 36% 57% 7% Improving Outcomes 68% 32% 0%

Improve Member Trust 68% 30% 2% Increasing Health Literacy 53% 45% 4%

Improve Utilization 45% 47% 8%

Management Programs Other

Reducing Costs 51% 45% 4% Reducing Technical Burden 45% 49% 6%

on CM and UM Staff
Care Management
Reducing Technical Burdens 28% 57% 15%
on IT Staff
Create Custom Care Plans 72% 25% 3%
and Journeys

Possibly even more interesting is the number of respondents that view

Reach More Members 66% 34% 0%
personalization as having a high impact on UM outcomes through reduced
Improve Care Manager 62% 36% 2% unnecessary utilization (60%), reduced costs (51%), and improved overall UM
Efficiencies programs (45%). These findings underscore the impact true personalization
can have when integrated into health plan care and UM programs.

Personalization can help health plans make sure the right care is being
provided to the right patient at the right time, driven by the right
communications. In order to do that, an organization truly has to
understand its customers.
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

DIGITAL CARE MANAGEMENT:

Driving Efficiencies to Reach More Members
As described above, most health plan care management, utilization Where Health Plans are Leveraging Digital-only
management, and population health management teams struggle Options
to maximize the impact they can have across the member base due
to limitations in technology. Earlier in this report we also discussed Respondents say their organizations run digital-only care
staffing limitations as barriers to optimizing the outcomes of these management programs for the following populations:
programs. This research also found that most health plan leaders do not
currently run digital-only CM programs. These digital-only solutions,
High-Risk Members YES
when combined with digital campaign outreach and telephonic CM, NO
can greatly increase the number of members reached by CM and PHM 15% 26% DON’T KNOW
teams. By automating certain tasks and streamlining interactions, the
burden on care managers is significantly reduced. This allows them
to focus on providing more CM interventions to a greater number of
members.
58%

Rising-risk Members

Digital campaigns can be a 17% 23%

strategic extension to reach
60%
more low- and rising-risk
members. Low-Risk Members

11%
21%

68%

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Health plan leaders unanimously recognize the value of digital When asked about population health management,
campaigns in engaging a broader member base. Approximately 43% respondents said they created automated, digital
intend to launch automated, digital population health campaigns
campaigns for the following populations:
specifically for members at rising risk, while 34% aim to focus more
on low-risk members. Given that CM teams primarily concentrate on High-risk members
higher-risk individuals, digital-only campaigns offer a strategic extension
60%
of their reach to include both low- and rising-risk members. Digital CM
programs can likely increase members’ engagement with their health. 28%

11%
Thinking about population health campaigns,
how valuable it is to generate automated, digital Rising-risk members

campaigns? 45%

43%
High-risk members
11%
51%
Low-risk members
47%
38%
2%
34%

Rising-risk members 28%

38%
WE DO THIS TODAY WE DON’T DO THIS WE DON’T DO THIS TODAY
62%
TODAY BUT PLAN TO AND DON’T PLAN TO

0%

Low-risk members Digital care management enables us

51%
to target members where they are and
47%
where they want care, and to meet
8%
them where they are in their health
VERY VALUABLE MODERATELY VALUABLE NOT VALUABLE journey. As a companion, rather than
as an adversary.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

DATA AND DATA MANAGEMENT:

Time to be Strategic
As one can surmise, the dominant, overarching theme from this research Remote member monitoring data: 40% of survey
is that personalization and contextual awareness of a member’s health respondents have remote member monitoring data but
is critical to driving improvements in care management, utilization
haven’t integrated it with workflows for CM or UM.
management, and population health management workflows and
enhancing outcomes. The ability to bring that personalization and
contextual awareness has been hindered by the lack of data. As the
volume of member health data available to health plans grows, the
Social determinants of health data: 40% of
opportunity to create greater contextual awareness and enhance the
value of UM, CM, and population health programs grows equally. Health
participating health plans have SDoH data but haven’t
plans have large datasets available to them today and have access to integrated it into CM workflows, and almost half have
even more — most are just not leveraging the data to effectively drive not integrated it into UM workflows.
personalization and make an impact on member outcomes at the health
inflection point.

That’s not to say health plans don’t use some of their data well. For UM, Fitness tracking data: 30% of respondents currently
nearly three-quarters leverage claims data, prescription information, and have member fitness tracking data but it is not integrated
clinical data from the provider’s EHR. Survey respondents also say their into CM workflows, and another 34% plan to acquire it in
organization leverages claims data, clinical data from the EHR, as well
the next 2 years; 34% have the data for UM, and 30% plan
as lab results for CM and PHM programs. However, they lack the ability
to access and use data from newer, and even some older, sources like to acquire it in 2 years.
social determinants of health (SDoH) data, remote member monitoring,
and member fitness tracking. Plans may have the data and use it, but
they are just as likely to have access to it and NOT have it integrated into
workflows. This indicates plans are not able to strategically leverage data
Additional data types: 33% of responding organizations
across the CM, UM, and PHM functions, which limits the impact these currently own but have not integrated call center activity
teams can have on understanding each member’s unique needs to create data, faxes, and ADT data into their workflows for CM.
the level of personalization needed to drive better outcomes.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Thinking about utilization management, how does

your organization leverage the following data sets?

Claims data 2% HEALTH PLANS ARE NOT STRATEGICALLY

72% 23% 4% USING THE DATA AVAILABLE TO THEM
Prescription SUCH AS ADT/HL7, CALL CENTER, SOCIAL
70% 17% 9% 4% DETERMINANTS OF HEALTH, AND REMOTE

Lab results MONITORING DATA.

58% 28% 9% 4%

ADT

55% 30% 9% 6%
Plans are not using data in real time to truly enable contextual awareness
Faxes
of their members and make an impact at the health inflection point.
47% 32% 15% 6%
Why not? They have the data but it’s not flowing into the hands of people
Call center activity data who can leverage it to drive down medical and administrative costs and
42% 38% 15% 6% improve the member experience.

SDoH data

32% 49% 13% 6%

Remote member monitoring data (blood pressure, weight, blood glucose, etc.)

23% 43% 23% 11%

Member fitness tracking

15% 34% 30% 21%

HAVE DATA AND HAVE DATA DO NOT HAVE DO NOT HAVE DATA
USE TODAY BUT HAVEN’T DATA TODAY BUT TODAY AND HAVE
INTEGRATED WITH HAVE PLANS TO, IN NO PLANS TO
WORKFLOWS THE NEXT 2 YEARS

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Thinking about care management, how does your Thinking about population health management,
organization leverage the following data sets? how does your organization leverage the following
data sets?
Claims data
2%
Prescription
68% 25% 4% 4%
77% 15% 6%
Lab results
2%
Claims data
66% 19% 9% 6%
72% 19% 8%
2%
Prescription
Lab results
64% 30% 4%
70% 19% 8% 4%
ADT
ADT
51% 32% 11% 6%
51% 32% 11% 8%
Faxes
Faxes
51% 34% 9% 6%
47% 30% 13% 9%
Call center activity data
Call center activity data
45% 36% 8% 11%
43% 36% 13% 8%
SDoH data
2%
SDoH data
34% 40% 17% 9%
36% 42% 21%
Remote member monitoring data (blood pressure, weight, blood glucose, etc.)
Remote member monitoring data (blood pressure, weight, blood glucose, etc.)
32% 42% 15% 11%
28% 36% 30% 6%
Member fitness tracking
Member fitness tracking
13% 30% 34% 23%
13% 30% 36% 21%

HAVE DATA AND HAVE DATA DO NOT HAVE DO NOT HAVE DATA
USE TODAY BUT HAVEN’T DATA TODAY BUT TODAY AND HAVE HAVE DATA AND HAVE DATA DO NOT HAVE DO NOT HAVE DATA
INTEGRATED WITH HAVE PLANS TO, IN NO PLANS TO USE TODAY BUT HAVEN’T DATA TODAY BUT TODAY AND HAVE
WORKFLOWS THE NEXT 2 YEARS INTEGRATED WITH HAVE PLANS TO, IN NO PLANS TO
WORKFLOWS THE NEXT 2 YEARS

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

Health plan leaders emphasize the critical importance of data access, Access to data in near real-time or real-time is vital for reaching
particularly valuing real-time or near real-time data for making timely members at critical inflection points, where their likelihood of
decisions at crucial health inflection points. However, when surveyed, engagement is highest. Engaging with members in real-time not only
respondents indicate that less than 30% of data across various domains increases the probability of improving health outcomes — as engaged
is available in real-time or near real-time, which is defined as within a members tend to be more adherent — but also allows health plans to
2-hour window. reduce administrative and operational costs. Additionally, this timely
engagement helps in avoiding unnecessary medical expenditures,
How would you assess the timeliness of data further optimizing the overall efficiency of health management
availability for your care management team? strategies.

Lab results

28% 68% 4%

ADT With the right healthcare

26% 61% 13%
data platform, our staff can
Call center activity data

25% 59% 16% drive timely interventions

Prescription
and be more proactive to
23% 70% 7%

Remote Member Monitoring Data* health needs, rather than

21% 70% 9%
reactive, to help members
Faxes

17% 72% 11% engage in their health

SDoH data

15% 75% 10%

journeys.
Claims Data

15% 78% 7%

Member fitness tracking

6% 66% 28%

REAL TIME DATA NOT REAL TIME DATA NA * Defined as blood pressure,
weight, blood glucose, etc.
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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

REGULATORY READINESS: How Care Management,

Utilization Management, and Data Integration Support
Current and Future Compliance
Better care management and utilization management workflows Although the efficacy of these workflows and processes is undeniable,
combined with better data integration and support are a must they face notable challenges in achieving regulatory compliance.
for improving outcomes for members and reducing unnecessary Approximately one-third of survey respondents identify technology
utilization and waste. These same workflows and access to data are limitations as a major obstacle to meeting regulatory standards, and
also very important to a health plan’s ability to respond to regulatory a similar proportion cites a lack of data sources as another significant
requirements. Nearly two-thirds (63%) of survey respondents say CM barrier. Consequently, transitioning away from outdated technology
and coordination workflows are important to their compliance with both platforms and strategically utilizing data are crucial steps for health
existing and potential future regulations. plans. These upgrades are essential, not only for compliance but also for
enhancing overall operational efficiency and effectiveness.
Thinking about care management and coordination,
how important are those workflows and processes
to being able to comply with existing and future
regulatory requirements?

88% OF HEALTH PLAN LEADERS SAY

63% 35% 2% POOR INTEGRATION OF DATA INTO

WORKFLOWS IS A BARRIER
Very Important Somewhat Not Important
Important TO REGULATORY COMPLIANCE.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

How much of a barrier are each of the following When asked about their readiness to comply with current and proposed
to managing regulatory compliance? regulations, about one-third say their organization has completed the
process to be able to comply with an advanced explanation of benefits,
Poor integration of data into the workflow a provider access API, and other proposed rules should those become
41% finalized, and roughly one-third are in the process of preparing to
47%
comply. Half of health plans are preparing to be able to comply with a
12%
proposed electronic prior authorization rule released early this year.
Technology limitations
33%
What is the status of your organization’s ability to
51%
16% comply with the following regulatory requirements?
Lack of appropriate data sources Electronic Prior Authorization Payer to Payer Data Exchage
27%
54% 42%
61%
25% 29%
12%
8% 13%
Lack of human resources 2% 8%
27%
59% Electronic Quality Reporting Submission Patient Access API
14% 48% 37%
27% 25%
Regulatory variability
12% 12%
25%
2% 4%
53%
22% Measuring Member Experience Metrics Advanced EOB
48% 37%
Lack of understanding of requirements
18% 23% 31%
61% 21% 15%
22% 4% 4%

Lack of real-time data Member Engagement (gap closures, Provider Access API
preventive screenings, compliance with
16% 33%
care plans)
67% 35%
18% 46%
12%
37%
8%
SIGNIFICANT BARRIER MODERATE BARRIER NOT A BARRIER 10%
4%

COMPLETE IN PROCESS PLANNING PHASE NOT ON RADAR

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

CONCLUSION
Today’s health plan leaders are navigating a complex interplay of
challenges and opportunities: Rising medical and administrative costs, Health plans should concentrate on the
compounded by enduring staffing difficulties, are accelerating the need to following strategic areas to maximize their
adopt transformational strategies that transcend conventional utilization
impact:
management, care management, and population health management
practices.

As this research shows, executives perceive existing CM, UM, and PHM
strategies, technologies, and workflows as only “modestly effective,” Strategic Data Utilization: Employing data to obtain contextual
signaling the imperative to adopt advanced technologies such as data insights is key to making more informed decisions within UM and
analytics, AI, and sophisticated automated workflows. CM processes.

Personalized Care Approaches: Customizing CM and population

The most critical and valuable health strategies is essential for making members feel recognized and
supported in their health journey.
resource is data. To unlock the full Intelligent Automation: By simplifying processes, minimizing manual
potential of digital assets, health tasks, and expediting decision making, health plans can enhance
outcomes and significantly reduce costs across medical, administrative,
plans need robust solutions that and operational domains.

are easy to use and effective at Transforming UM, CM, and PHM requires an adaptable clinical data

increasing efficiencies and driving platform that provides a comprehensive contextual understanding of
individuals and automates the subsequent personalized best actions —

down costs while improving from simple campaigns to intricate CM and utilization approvals — to
optimize health outcomes. That transformation will empower utilization

engagement and experience. management with automation, AI and data to drive greater efficiencies
that reduce administrative and medical costs while also delivering a more
engaging member experience.

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THE STATE OF UTILIZATION MANAGEMENT AND CARE MANAGEMENT | 2024

SOURCES & METHODOLOGY

Sources: Respondents Plan Types the Organization Offers

1 Medical cost trend: Behind the numbers, PwC 23% VP/Director of Operations 77% Commercial – fully insured

18% Other C-Suite (CIO, COO, CFO, CMIO) 66% Medicare Advantage
2 High U.S. healthcare spending: Where is it all going?,
The CommonWealth Fund 11% Chief Medical Officer 53% Dual eligible plans

3 2024 Outlook for Healthcare, Deloitte 11% VP/Director Utilization Management 51% Commercial – self-insured

4 The untapped potential of payer care management, 10% Other VP/Director (Care Management 51% ACA plan
and Coordination, PHM)
McKinsey & Company 45% Managed Medicaid
10% Manager (CM, UM, Operations)
5 2022 CAQH Index, Council for Affordable Quality 13% Tricare
Healthcare 8% Chief Executive Officer
6% Other
5% Other
6 2020 CAQH Index, Council for Affordable Quality
Healthcare 4% Manager Clinical Care Coordination
Total Lives Covered
7 The untapped potential of payer care management,
23% Between 100,000 and 249,999
McKinsey & Company Type of Health Plan
17% More than 5 million
26% Regional payer
15% Less than 25,000
23% Government program plan (Medicare
13% Between 250,000 and 1 million
Research Demographics Advantage, Managed Medicaid, or both)

19% National payer 13% Between 50,000 and 99,999

Medecision commissioned healthcare 11% Between 25,000 and 49,999
17% Managed services organization
consultancy Sage Growth Partners to conduct
6% Provider sponsored health plan (PPS/ 8% Between 1 million and 5 million
independent research. The survey included Payvider)
53 respondents, spanning CEOs, CIOs, Chief 6% TPA - Medicare or Medicaid U.S. Region Plan Location
Medical Officers, Chiefs of Population Health,
4% Tech-enabled and/or venture-backed 28% National
and VPs from at least 24 unique organizations. health plan
17% New England
Participants represent a range of functions:
15% Mid-Atlantic
care management, care coordination,
11% Southeast
utilization management, and operations.
Survey respondents were screened to ensure 11% West

familiarity with their organization’s approach 6% Great Lakes

to care management, utilization management, 4% Great Plains

and population health management. 4% Southwest

4% Mountain

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About Medecision About Sage Growth Partners
Fully delivering on the promise of data — and making the business Sage Growth Partners is a healthcare advisory firm with deep
of healthcare simpler and more successful — Medecision offers a expertise in market research, strategy, and communications.
whole new world of possibilities. The company’s flagship offering, Founded in 2005, the company’s extensive domain experience
AerialTM, stands as the market’s most extensible clinical data ensures that healthcare organizations thrive amid the complexities
platform. It offers complete contextual awareness of members and of a rapidly changing marketplace. Sage Growth Partners
automates next best actions - simple campaigns, complex care serves clients across the full healthcare spectrum, including GE
management, utilization approvals, and more - for optimal health HealthCare, Medecision, ProgenyHealth, Kyruus, Together Senior
outcomes. Health, Best Buy Health, New Jersey Brain and Spine, the National
Minority Health Association, and Philips Healthcare. For more
Aerial is not only quick to deploy, it is easy to manage.
information, visit https://sage-growth.com/.
The platform’s effectiveness in reducing both medical and
administrative costs, coupled with its role in improving the member
and patient experience, has made it the preferred choice for
health plans and care delivery organizations. Presently, Aerial is
instrumental in catering to over 10% of the U.S. population, marking
a significant milestone in advancing healthcare efficiency and
effectiveness. www.medecision.com

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