Clinical Programs & Total Cost Of Care Strategy

Mini-White Paper: Lower Costs And Clinical Programs

Employers are continually looking for ways to control costs and improve the quality of healthcare for their employees. Using a Total Cost of Care approach, better clinical program management can result in significant savings.

Help your organization lower costs by ensuring employees get the right care from the right provider at the right place and time. Get a clearer picture of how clinical programs are a key component of an effective Total Cost of Care strategy with the mini-white paper below.

Together with your health plan partner, you can use a Total Cost of Care approach to deliver better results for your employees and your organization’s bottom line.

Optimizing Total Cost of Care through clinical programs

Employers are continually looking for ways to control costs and improve healthcare quality for their employees. By utilizing advanced and better managed clinical programs, your organization could achieve substantial savings through a Total Cost of Care (TCOC) approach.

Total Cost of Care: the big picture

Total Cost of Care refers to the total amount an organization spends on healthcare and health benefits for employees and their dependents. There are four key components of TCOC:

network and benefit design, member engagement, clinical programs, and cost protection.

By viewing it all through a Total Cost of Care lens, you can gain a clearer picture of potential solutions that can make a meaningful impact on the health of your workforce and your organization’s bottom line. Let’s dive deeper into clinical programs to learn more.

Why are the right clinical programs important?

Effective, data-driven clinical programs ensure employees are getting the right care from the right provider at the right place and time, particularly those with chronic or high-cost conditions. Given that 90% of annual healthcare expenses are attributed to people with chronic and mental health concerns, employers can achieve significant savings through improved care management.1 This approach can lead to fewer emergency room visits, lower hospitalization rates, increased preventive screenings, and other savings.

The cost of hospital stays and related services increased by 4.2% last year.² Clinical programs can help mitigate the rising costs of condition management.

Whether it’s integrating medical and pharmacy benefits, implementing care management, or bringing behavioral and physical health together, there are several ways to achieve more effective clinical programs.

Population health management	Care management for at-risk employees	Integrated medical and pharmacy benefits	Integrated physical and behavioral healthcare
Better allocate healthcare resources by understanding employees’ needs. This can be done through identifying at-risk employees, gaps in care, and opportunities for collaboration between providers.	Take a comprehensive approach to care management through high-touch, employee-centric care supporting employees’ whole health, which helps reduce costs through early and targeted intervention and guidance.	Through integrated medical and pharmacy benefits, your health plan can have real-time access to important prescribing data to more appropriately manage your employees’ care.	By integrating physical and behavioral healthcare, you could see cost savings and a reduction in hospitalizations. This also gives employees the ability to address mental health concerns in a primary care setting, resulting in better outcomes.
Lack of care coordination accounts for $27.2-$78.2B in wasted healthcare spending each year.³	$147B in annual productivity losses are due to chronic conditions like heart disease and stroke.¹	4% lower annual medical costs, with an associated average medical cost savings of $148 per member per year — specifically, $3,601 with carve-in versus $3,749 with carve-out or a separate pharmacy benefit.⁴	57% of commercial healthcare spending is driven by behavioral health patients.⁵

Population health management
Better allocate healthcare resources by understanding employees’ needs. This can be done through identifying at-risk employees, gaps in care, and opportunities for collaboration between providers.
Lack of care coordination accounts for $27.2-$78.2B in wasted healthcare spending each year.³

Care management for at-risk employees
Take a comprehensive approach to care management through high-touch, employee-centric care supporting employees’ whole health, which helps reduce costs through early and targeted intervention and guidance.
$147B in annual productivity losses are due to chronic conditions like heart disease and stroke.¹

Integrated medical and pharmacy benefits
Through integrated medical and pharmacy benefits, your health plan can have real-time access to important prescribing data to more appropriately manage your employees’ care.
4% lower annual medical costs, with an associated average medical cost savings of $148 per member per year — specifically, $3,601 with carve-in versus $3,749 with carve-out or a separate pharmacy benefit.⁴

Integrated physical and behavioral healthcare
By integrating physical and behavioral healthcare, you could see cost savings and a reduction in hospitalizations. This also gives employees the ability to address mental health concerns in a primary care setting, resulting in better outcomes.
57% of commercial healthcare spending is driven by behavioral health patients.⁵

Clinical programs in action

By implementing effective clinical programs supported by employee engagement, you can optimize the benefits for both your workforce and your organization's bottom line.

Here’s an idea of how the right pieces come together:


Right providers Quality and transparency tools help employees identify the right provider, from primary care to specialists. This can lower the cost of employees’ overall care and streamline the experience.	Right place Drive lower hospitalizations and ER visits by ensuring employees know where to go for care. This can be done by expanding access to urgent care and lower-cost settings, such as freestanding labs or surgery centers.
Right care Building a fuller picture of employee health with integrated care can raise efficiency and effectiveness.	Right time Data can help make predictions about things such as care gaps and health risks to provide more timely care.


Right providers Quality and transparency tools help employees identify the right provider, from primary care to specialists. This can lower the cost of employees’ overall care and streamline the experience.
Right care Building a fuller picture of employee health with integrated care can raise efficiency and effectiveness.


Right place Drive lower hospitalizations and ER visits by ensuring employees know where to go for care. This can be done by expanding access to urgent care and lower-cost settings, such as freestanding labs or surgery centers.
Right time Data can help make predictions about things such as care gaps and health risks to provide more timely care.

Engage your health plan partner

Here are a few questions to ask your health plan partner in order to gain a better understanding of your current clinical programs:

What can we do together to drive better engagement and more effective use of clinical programs?
What programs do you offer to encourage collaboration across pharmacy and clinical programs?
How are you using data to drive better outcomes?
What new solutions are being offered to help better integrate and manage the care of my employees?

Questions? We’re here to help. Contact your account management team, broker, or sales representative for more information. Together, we can determine the right Total Cost of Care approach for your organization’s needs.

1 Centers for Disease Control and Prevention: Health and Economic Costs of Chronic Diseases (accessed July 2023): cdc.gov.

2 Peterson-KFF Health System Tracker: How does medical inflation compare to inflation in the rest of the economy? (accessed July 2023): healthsystemtracker.org.

3 National Library of Medicine: Waste in the US Health Care System: Estimated Costs and Potential for Savings (accessed July 2023): ncbi.nlm.nih.gov.

4 Journal of Managed Care + Specialty Pharmacy: Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits (accessed July 2023): jmcp.org.

5 Modern Healthcare: Behavioral health patients spur 57% of commercial healthcare spending (accessed July 2023): modernhealthcare.com.

Drive Savings With Clinical Programs Within A Total Cost Of Care Approach