By managing chronic conditions proactively, we help plans avoid high-cost events (ER visits, admissions). For example, consider a member with diabetes and hypertension – under our program, they are more likely to keep those in control, avoiding expensive complications like stroke, dialysis, or hospitalization for heart failure. A Medical Group Management Association note indicated CCM programs reduced costs by about $74 PMPM in Medicare population – health plans see that kind of ROI directly in claims. If we deploy to a plan’s high-risk cohort, the ROI could be even larger (since those are the costliest members).

We significantly boost the metrics health plans care about. For Medicare Advantage, we help with Star measures: controlling blood pressure, A1c control, medication adherence (since we assist with refills and compliance), reducing readmissions, getting members in for AWVs, etc. For Medicaid, we can impact measures like ED utilization, preventive screening rates, and chronic care follow-up.

When a health plan provides a service like Brilliant Care for its members, it differentiates itself with a higher-touch experience. Members feel their plan is truly looking out for them, not just paying claims. Our nurses develop relationships with members – often members will say “my nurse from the health plan calls me and she really cares.” This can reflect in higher CAHPS scores and Net Promoter Scores for the plan. Happy members are more likely to stay with the plan (improving retention). It’s especially important in Medicare Advantage where members have choices annually.

Plans often worry about whether providers are doing enough care management – but providers are busy. We act as the plan’s extension to ensure care management is happening without adding burden to providers. We coordinate with providers, but we don’t depend on them to drive it. This is useful particularly in broader networks where plan can’t directly mandate each practice’s approach. We essentially ensure plan initiatives (like reducing readmissions or closing gaps) are executed across the network uniformly.

We collect a lot of data on members – home vitals, self-reported health status, SDOH needs, etc. We share this data (in a HIPAA-compliant manner) with the plan’s care management systems. This enriches the plan’s understanding of their members. For example, we might flag that a member has issues affording meds (SDOH), or that they have uncontrolled home BP readings. The plan can use that for risk stratification or adjusting care programs. Essentially, we act as eyes and ears in between claims data points, feeding valuable info back.

We can scale to thousands of members relatively quickly as a centralized service. Health plans, especially large ones, need partners who can cover large populations. We have the infrastructure (technology, call center capacity, multilingual staff if needed) to scale across a plan’s membership as needed, focusing on whatever segment (often high-risk or rising risk) they target.

If the plan already has internal case managers, we integrate and collaborate. We might take on the more routine monthly management while their case managers focus on the most complex cases, or vice versa. If the plan offers digital tools (like a member portal or app), we complement that with human touch – often boosting engagement in those tools. For example, if a plan offers free digital blood pressure cuffs, we not only get members to use them, but we also act on the readings, which closes the loop of value.