The hidden cost of the “high-risk” member: Why health plans must look beyond the diagnosis

In the world of Medicare Advantage (MA), the term “high-risk member” is often narrowly defined by clinical data: a list of chronic conditions, a history of falls, or a high Hierarchical Condition Category (HCC) score.

For health plans, these members represent the greatest challenge to the bottom line. They are the cohort of the population driving the majority of healthcare spending through emergency department visits, polypharmacy complications, and inpatient stays. But if you are only looking at high-risk members through the lens of existing claims, you’re missing the hidden drivers that turn a stable member into a high-cost crisis.

To truly mitigate risk and improve Star Ratings, health plans must look beyond the diagnosis to the daily realities of aging, independence, and care.

The root cause of a high-cost claim

When we look at a claims report, we see numbers. But behind those numbers are the root causes that standard data points often miss:

• The fall risk: Physical instability and environmental hazards often go unnoticed in standard health assessments. Without proactive identification of mobility limitations, members remain at high risk for catastrophic injuries like hip fractures, which often serve as the primary catalyst for a permanent move to long-term care facilities and a sharp spike in acute claims.
• The polypharmacy puzzle: Many members manage multiple chronic conditions with a complex web of prescriptions from different specialists. Without a centralized view of these medications, the risk of adverse drug interactions and non-adherence increases significantly, leading to avoidable emergency room visits and preventable medical crises.
• Social isolation: Loneliness is a significant non-clinical driver of poor health. The psychological strain of isolation and the lack of a nearby support system can lead to the rapid deterioration of physical health, exacerbating conditions like hypertension and depression while creating barriers to effective self-care and recovery.

For a health plan, these aren’t just lifestyle issues—they are financial liabilities. When social needs and functional declines go unaddressed, they manifest as catastrophic claims that impact your Medical Loss Ratio (MLR) and overall plan performance.

Identifying high-risk members

To mitigate the cost a high-risk member may bring, health plans need a way to intervene before an issue becomes a crisis. This is where Cleo’s Health Pulse comes in.
Cleo’s Health Pulse is a comprehensive, member-completed assessment designed specifically for the Medicare Advantage population. It provides a window into a member’s physical, mental, and social health that claims data simply cannot capture.

While the industry often talks about Social Determinants of Health (SDoH), Cleo Health Pulse focuses on Health-Related Social Needs—the immediate, actionable factors that impact a member’s ability to stay healthy and independent.

How Cleo identifies and mitigates risk:

1. Anticipating needs: By screening for mobility limitations, fall risks, and activities of daily living (ADLs), Cleo’s Health Pulse identifies members who need home modifications or physical therapy before a fall occurs.
2. Addressing mental health & loneliness: It flags members experiencing early signs of anxiety or isolation, allowing Cleo’s mental health coaches to step in before these issues lead to clinical decline.
3. Proactive care navigation: Members with polypharmacy concerns or financial strain are immediately connected to resources, ensuring adherence and safety.

Improving your bottom line by supporting those most at risk

The impact of Cleo Health Pulse is clear: it turns hidden high-risk members into supported members.

• Higher engagement: In our pilot, 67% of enrolled MA members completed the Health Pulse, proving that members want to share their stories and are seeking support.
• Targeted interventions: By identifying the members who need help with daily activities like dressing or bathing, Cleo helps plans coordinate the exact care needed to prevent institutionalization.
• Reduced claims: By addressing the root causes—loneliness, medication safety, and fall prevention—plans can significantly reduce the frequency of high-cost acute events.

A high-risk member doesn’t have to be a high-cost claim. Cleo provides health plans with a deeper understanding of the physical and social forces shaping your members’ lives, helping you move from reactive management to proactive care.

Supporting independence and aging in place isn’t just the right thing to do for your members—it’s the most effective strategy for protecting your bottom line.

Learn more about Cleo for Medicare Advantage or get in touch today.