Tufts Health Plan is Leading the Way in Cost Management

At Tufts Health Plan, we believe that the key to lower health care costs is better health care. It’s as simple as that.

Every day we’re looking for innovative strategies to control costs on every front, from prescription drugs to wellness initiatives to coordinated care management. Our goal is to ensure members get the best, most appropriate care.  

three people at a casual business meeting

87% of employers say rising pharmacy costs are a top priority.1


Here’s how we’re making care more affordable for members, and keeping rising premiums in check for employers and their employees.

1. Our prescription for a better way: Seamless transition, simple solutions

We know drug costs are one of employers’ and employees’ top concerns. So we’re tackling the problem from all sides, using a range of proactive and innovative strategies to help control pharmacy costs.

  • Flexible programs & plan options: Tufts Health Plan tailors pharmacy plans to meet employers’ specific needs, using multi-tier plan designs to maintain flexibility and encourage members to use lower-cost and preferred brand name drugs.
  • Close monitoring of medication compliance: Our targeted program is focused around chronic conditions, using specialty pharmacy care teams to help ensure adherence to complex—and expensive—medication schedules for better outcomes.
  • Active management of specialty drugs: We take a proactive role to secure price protections, reassess preferred drug strategies, and negotiate rebates for all new drug launches.
  • Pharmacy Benefits Manager: At Tufts Health Plan, we believe in an integrated approach to pharmacy benefits, not just because it can lead to tremendous cost savings for members and employers, but because it’s the best way to offer quality, fully-coordinated care to our members.

In the past 3 years Tufts Health Plan has saved $30 million in medical and pharmacy costs.


2. Collaborating with providers

Doctors love us, and we love them. Across the board at Tufts Health Plan, we believe care is better and more cost effective when health plans and providers work together. By sharing data and collaborating closely with our providers, Tufts Health Plan is supporting a more expansive view of patients and ensuring more appropriate care.

A single view of the member unifies how we approach their care:

  • Shared clinical record offers a 360-degree view of every member.
  • Medication oversight for higher compliance rates.
  • Care coordination from admission to discharge.
  • Integrated care team attuned to both medical and behavioral health needs of all members.
  • A simplified referral process for more common, cost-effective treatments.

3. Doing well by doing good for members with chronic conditions

Helping individuals with chronic conditions manage their care, from treatment adherence to lifestyle changes, can help minimize costly complications. And our goal isn’t just reach—it’s engagement.

Our care management team engages nearly 93% of the members we reach with our critical programs. That includes:

  • Members with chronic kidney disease.
  • Patients returning home from the hospital.
  • High-risk moms-to-be.
  • Pediatric patients released from the NICU or hospital.

4. Making life better for sick employees

Our registered nurses work one-on-one with members with high-cost diagnoses. When members engage with our RNs, they work together to define and achieve members’ personal health care goals.

At Tufts Health Plan, care management is about:

  • How we connect with our members.
  • How we analyze our data. 
  • How we manage claims and care with compassion.
  • How we manage the pharmaceutical side of treatment.
  • How we collaborate with the provider care team.
  • How we help ensure patients get the right test, and the right care at the right place at the right time, ultimately reducing gaps in care.

5. Reducing ER usage

Our Emergency Department Program follows up with members who visited the ER for issues like ankle sprains and sore throats, who could most likely have sought care in a more appropriate setting, such as urgent care. Registered nurses provide support and education related to follow-up care.

As a result we've reduced ER usage:

  • A significant increase in urgent-care usage for subsequent care for those members managed in the program.
  • A 45% reduction in mean admits-per-1000 for members managed in the program.
  • A 60% reduction in mean ER visits-per-1000 for members managed in the program.
  • Increased referrals into our care management program.

6. Meeting the unique needs of diverse populations

Diversity and inclusion are core elements of our mission at Tufts Health Plan. We’re constantly working to improve the health and wellness of the diverse communities we serve.

Using both data and member feedback, we’ve developed a variety of programs and outreach efforts to address health disparities and maximize access to quality care:

  • Introduced Select Network HMO to encourage the use of high quality, lower cost providers.
  • Breaking cultural barriers to gain acceptance of primary care physician adoption to lower ER visits.
  • Community outreach events to facilitate open enrollment. 
  • Custom multilingual communications to promote open enrollment, preventive services, healthy choices, and member programs.
  • Custom mobile-enabled microsites in Spanish, French, Chinese, and Kréyòl.
  1. Willis Towers Watson. (2017) High-Performance Insights—Best Practices in Health Care Employer Survey.