Southeast
health plan

Up to $25M in validated cost savings across five targeted social risk cohorts for one employer group

Measurable impact

A recent opportunity assessment evaluated the financial impact of integrating social risk into payer analytics. Independent actuarial analysis quantified and validated the significant opportunity social risk presents in driving material cost variation. Employing modeled interventions, the organization can expect to achieve:

Up to
$M
in savings across
5 targeted cohorts
Up to
:1
ROI when interventions align
to social risk drivers of cost
Up to
$M
in savings for one cohort
of 5,000 members

The story behind the numbers...

The Challenge

Traditional claims data was insufficient to explain why members with similar medical conditions had such variability in costs and outcomes. Looking at social risk as a potential driver, this employer sought to understand the prevalence of social risk factors, their impact on claims costs, and opportunities for targeted interventions while bearing full financial risk.

About the client

  • Locally owned with deep community ties
  • Serving individuals, employers and government programs
  • Many partners enhance their capabilities
  • One employer client covers almost 500,000 members under an ASO/commercial contract

The Solution

The health plan employer group client leveraged MedeAnalytics’ Social Risk Insights Measures & Outcomes solution, a unique, integrated methodology that delivers a comprehensive cloud-based infrastructure to identify, stratify, intervene, and demonstrate the value of social risk programs.

This methodology was delivered through an opportunity assessment that was conducted over a 90-day period as a decision gate to quantify and validate priority opportunities before committing operational dollars. The key steps included:

Identifying and scoring individual-level social risk across five social determinants of health domains

Integrating social risk, medical, and pharmacy data into a unified analytics dataset

Stratifying the population to identify high-risk, high-cost cohorts

Applying actuarially validated modeling to estimate per member per month (PMPM) cost savings for high-impact cohorts

Providing an option to transition to an uninterrupted and ongoing partnership to measure and validate realized ROI over time

Presbyterian is already working on plans to further their predictive and optimization analytics with MedeAnalytics innovative solutions.

The Results

The opportunity assessment identified five high-impact population cohorts, representing up to $25M in validated savings potential. This included up to $6.6M attributable to pregnant women with stacked risks within a sub-population of just 5,000 members.

In addition to the quantified statistics, the assessment showed:

  • Meaningful PMPM lift observed among members with elevated social risk compared to clinically similar peers​
  • Stacked social risk compounds cost, with multi-risk members showing approximately 25% higher total cost​
  • Incremental cost is concentrated in identifiable high-risk cohorts, making targeted investments predictable​
  • Targeted cohorts demonstrate up to 3:1 ROI when interventions are aligned to the specific social risk drivers of cost

ROI results are pending measurement and validation over a period of 12–15 months. MedeAnalytics leverages AWS and our Health Fabric to unify diverse healthcare and social data sets into a secure, scalable environment—enabling rapid data sharing, streamlined access, and real-time collaboration across partners.

“MedeAnalytics has been very responsive during our implementation. They are willing to find a solution to any issue we’ve brought to them. [...] It is mind-blowing how fast they're able to update the coding and turn it around for testing.”

Director of Client Reporting

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