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Chronic and At-Risk

Chronic and At-Risk

Chronic conditions are the leading drivers of rising health care costs.

According to the CDC, chronic diseases are the leading drivers of the nation's $4.1 trillion in annual health care costs, and 4 in 10 adults in the US have two or more chronic conditions.* MedCost reaches out to those with at-risk and rising risk conditions requiring personalized nurse coaching and education. Common chronic conditions that put employees at risk include asthma, congestive heart failure, COPD, diabetes, high blood pressure and high cholesterol. MedCost also uses predictive analytics to help target and provide outreach to individuals as we enroll them into the appropriate care management program. By measuring risk score changes over time, we are able to track health improvements ensuring our interventions are effective.


Personal Care Management

Personal Care Management (PCM) is individualized care designed to help create positive outcomes for those who are suffering from chronic conditions. Our nurse coaches use one-to-one collaborative conversation with targeted interventions to strengthen a person’s own motivation and commitment to change. Our nurses partner with individuals to ensure their conditions are well managed from the clinical perspective. But that's just part of the story. They also encourage participation in our wellness programs that focus on forming healthy habits needed for long-term behavior change.

Transitional Care

The goal of transitional care is to prevent avoidable hospital readmissions. A study conducted by the University of Pennsylvania Perelman School of Medicine found that patients were nearly 70% less likely to be readmitted if they had a primary care physician follow-up visit within 30 days after discharge.* The transitional care provided by MedCost coordinates care among providers to help ensure these follow-up visits occur.

MedCost transitional care nurses focus on providing pre- and post-admission counseling to individuals who have pre-planned surgeries. This care team will be with you throughout your transition from the hospital and will contact you within one business day of discharge to discuss medication, side effects, and signs and symptoms of complications, and ensure the follow-up appointment has been made. Transitional care post-admission counseling also is provided to those individuals with unplanned hospital admissions and a clinical condition with a higher likelihood for readmission.

*JAMA Surgery, September 2023, Primary Care Physician Follow-Up and 30-Day Readmission After Emergency General Surgery Admissions

Chronic Condition Education

MedCost works to educate at-risk individuals who have been identified with asthma, congestive heart failure, COPD, diabetes, high blood pressure or high cholesterol. Through reminders and communication, we work to keep good health practices top of mind.

SmartStarts Maternity Management

As of 2021, 10.5% of all births in the United States were premature.* Common results of preterm births include heart and respiratory conditions, developmental delays, abnormal growth rates and visual problems that can impact a child for years to come. The MedCost SmartStarts program focuses on providing education and support to all expectant mothers with the goal of reducing preterm births and days in a costly neonatal intensive care unit (NICU). SmartStarts is open to all expecting mothers, regardless of the risk level associated with their pregnancy. Enrollment includes an extensive medical history to help identify potential risk factors. Specialized MedCost prenatal nurses monitor the condition of the expectant mother throughout her pregnancy and after delivery to reduce risks associated with complicated pregnancies and premature births.


On-Staff Pharmacist

Our staff pharmacist uses advanced analytics to provide timely interventions to help manage the rising costs of pharmaceutical spend. The pharmacist works hand-in-hand with our care management programs to evaluate medications for appropriateness, side effects, contraindications and lower cost alternatives when appropriate. Our in-house pharmacist collaborates with our PBM partners to identify and reduce pharmacy gaps in care such as medication adherence, brand to generic prescribing opportunities, drug administration site-of-care review and conservative therapy evaluation.

Telehealth Services

Telehealth services, including consultations by phone, apps or videoconferencing, are on the rise as employers make medical care more accessible, affordable and convenient for their busy employees. Many acute health concerns can be treated without incurring the expense of an office visit, urgent care facility or emergency room visit. Conditions such as respiratory and urinary tract infections, allergies, anxiety, muscle and arthritic pain, and minor joint sprains and strains can all be treated via phone or mobile device. Employees have 24/7/365 access to doctors licensed to practice medicine in their respective states. A Caregiver Program also allows employees to add an elderly or sick relative to their account and arrange video or phone visits for a flat fee. Telehealth can be added to your health plan at any time.

Behavioral Health

Those employees with higher usage rates of medical services, such as those with chronic health conditions, typically have a higher prevalence of depression and anxiety disorders. MedCost nurses routinely conduct depression screenings as part of our Personal Care Management, Complex Case Management and SmartStarts Maternity Management programs. Participants in any of these programs may be directed to contact their doctor for additional follow-up and referred to resources available through Healthy Mind and Telehealth. We ensure individuals have access to the most appropriate level of care with certification review of residential programs, partial hospitalization and intensive outpatient care.

Cost Comparison Tool

Powered by health plan data and claims information, the Cost Comparison Tool reveals the costs of hundreds of common medical services on a member-specific level and can help your employees make more informed, cost-effective care decisions. Patient reviews and quality ratings provide additional context and information about the providers. Shopping for care is easy for employees—the tool is available in their secure member account. The Cost Comparison Tool meets the requirements of both the Payer Transparency in Coverage rule’s self-service shopping tool and the No Surprises Act’s price comparison tool.