Risk Assessment & Cost Management

Risk assessment and cost management often go together in the healthcare field. The damage control insurance companies partake in is changing.  This is because insurers cannot prevent high cost/high risk patients from going under their insurance. While marketers are doing more and more to capture the ideal patients, it is impossible to “keep out” high cost patients. From there, it is the job of insurers to keep costs down, and that involves being proactive and weighing risks.


Defining what constitutes as risky behavior is important.

Insurers mainly define risk as anything that increases their costs of care (such as frequency of visits), thus decreases profits.

Over time, insurers have become more cognizant and have created expansive definitions of risk. For example, risk managers have taken into account the actions of hospitals and physicians in the grand scheme. They take into account the costs associated with repeated hospitalization. This has led to more healthcare companies’ risk and quality sectors to completely merge, or actively share data.

There is more information that is taken in to not just analyze risk, but to also prioritize this risk. For example OptumHealth created a model that considered  stress, lack of physical activity, high cholesterol, high blood pressure, high body weight and use of anti-anxiety/depression medications to determine whether a patient is high risk. If a patient fulfilled six of the nine criterions, they are considered overall high risk.

This model is effective because it acknowledges two things: 1) that risk is multifaceted; an individual can be determined “at risk” for multiple reasons and 2) that it allows for risk analysts to weigh outside and independent environmental factors in how an individual becomes high risk.