Identifying the true cost of falls has been intrinsically difficult for health plans due to inaccurate coding on injurious falls. And, only 1 in 6 falls require emergency care.

While some view falls as episodic, they are more akin to chronic conditions - like heart failure. Costs ramp up prior to an individual’s first injurious fall - and (without intervention) continue to escalate after the fall.

Calculating the cost of falls

Using recent Medicare beneficiary claims data, Nymbl engaged actuarial firm Axene Medical Partners to calculate the most up-to-date available costs of acknowledged chronic conditions and falls per member per month (PMPM), as well as the annual total claims cost of each condition per member.

We leverage this data in our Balance and Aging report - to put the magnitude of the cost of falls into perspective. This report further investigates falls as a chronic condition while presenting Nymbl as a fall prevention solution. By treating falls as a chronic condition (with early intervention tailored to member ability level), Nymbl is able to impact the entire member population.

Sample requirements and size

With a 5% sample size, claims data was limited to traditional Medicare beneficiaries who have both Part A and Part B coverage, are 65 years or older, and are not in hospice.

Analysis of falls cost

As the graphs reveal, not only do falls cost plans more PMPM than many other chronic conditions - they also cost more on an annual basis. This annual amount represents the fact that many fallers continue to fall or experience declining independence that requires increasing reliance on healthcare services. In this way, the progression of a faller is similar to that of a heart failure patient.

71% of older adults with a fall-related claim (FRC) have a subsequent FRC within 12 months (subsequent FRC are more costly than the initial claim).¹

In our Balance and Aging report, we discuss how balance declines with age - making people more prone to falls as they get older. We also show why Nymbl’s solution is best positioned to impact falls at the population level.

Since we are completely confident in our solution, we go at-risk to prove that Nymbl delivers a 3:1 ROI across all enrolled members within 12 months.

Source:

1. Courtney T, Estrada N, Mirsky B. Identifying Medical Spend for Older Adults with Injurious Fall Related Claims- Lessons Learned. Wakely x Nymbl White Paper. April 2023, https://5113115.fs1.hubspotusercontent-na1.net/hubfs/5113115/White%20Papers/Identifying%20Medical%20Spend%20Older%20Adults%20Injurious%20Fall-Related%20Claims%20-%20Lessons%20Learned.pdf.