The following brief helps Medicare Advantage (MA) health plans understand the fall risk of their population, the total medical cost from falls, and the potential medical cost savings achievable in the next 12 months if the MA plan intervenes on this problem.

Understanding balance and fall risk

To first understand the cost of falls, we need to look at the prevalence and impact of falls. Falls are the leading cause of injury and accidental death among adults over 65 in the U.S., causing an average of 74 deaths every day.¹ As the aging population continues to grow, the frequency and associated cost of falls will continue to rise - amounting to billions.

The balance reflex can be improved

As one ages, a decline in balance is often the result of a reduced balance reflex; when an individual becomes unsteady, they cannot “catch themselves” quickly enough due to the decline of this reflex. While this decline is natural, the balance reflex can be re-trained through dual-tasking (Nymbl’s patented approach to balance training that combines body and brain exercises together). Retraining the balance reflex significantly reduces fall risk - making high risk fallers less likely to fall and ensuring lower risk older adults never degrade to high risk.

Fall risk stratification

There is significant complexity in evaluating the fall risk profile of a Medicare Advantage (MA) population due to the diversity in ages and risk factors present. Nymbl partnered with independent actuarial firm Axene Health Partners to develop a robust methodology for understanding fall risk. This collaboration focused on analyzing risk factors, associated claims data, and cost-saving outcomes from real-world MA plan data. The resulting Axene model utilizes a data set derived from the 5% Medicare Limited Data Set (LDS), encompassing 15 million member months and representing 1.2 million members.

Among its many discoveries, Axene found that, to predict falls accurately, an MA population is best divided into four risk categories, each behaving differently based on their injurious fall rates:

Medical cost of falls

Based on these risk classifications, we can calculate the medical cost of falls for MA populations. For this brief, let’s look at an imaginary MA plan with 100,000 members. The total cost is calculated based on a normative MA population, with an assumed cost of $12,000 per fall. 

1. Existing/severe risk:
   Members in this category are those who have:
   1. Had a fall-related injury, wrist fracture, diagnosis claim, or 
   2. Had a procedure (such as a scan or repair) in either an in-patient or out-patient setting, or 
   3. Had an inpatient stay due to a hip fracture.
      • • Prevalence in an MA population: 10%
        • Injurious fall rate: 36%
        • Number of injurious fallers = 100,000 members * 10% prevalence * 36% fall rate = 3,600
        • Total category cost: 3,600 injurious fallers * $12,000 per fall = $43.2 million
          
          
2. Serious risk:
   Members in this category are those who have:
   1. Had a fall-related injury indicating a higher risk of future major falls, but not requiring inpatient care, or
   2. Sustained multiple injuries within a year (2 injuries), or
   3. Sustained one injury within a year.
      • •     Prevalence in an MA population: 15%
        •     Injurious fall rate: 13%
        • Number of injurious fallers = 100,000 members * 15% prevalence * 13% fall rate = 1,950
        • Total category cost: 1,950 injurious fallers * $12,000 per fall = $23.4 million
          
          
3. High risk:
   Members in this category are those who have:
   1. Screened as high-risk for falls using Nymbl’s STEADI risk assessment, which aligns with the American and British Geriatric Societies’ best practice guidelines known as Stopping Elderly Accidents, Deaths and Injuries (STEADI). 
      • • Prevalence in an MA population: 15%
        • Injurious fall rate: 13%
        • Number of injurious fallers = 100,000 members * 15% prevalence * 13% fall rate = 1,950
        • Total category cost: 1,950 injurious fallers * $12,000 per fall = $23.4 million
          
          
4. Moderate risk:
   All other members. 
   • • Prevalence in an MA population: 60%
     • Injurious fall rate: 6%
     • Number of injurious fallers = 100,000 members * 60% prevalence * 6% fall rate = 3,600
     • Total category cost: 3,600 injurious fallers * $12,000 per fall = $43.2 million

Totaling the costs from each risk category results in a total medical cost of falls of $133.2 million for an MA plan with a population of 100,000 members, or $111 PMPM across the entire population regardless of risk. This high cost further illustrates the widespread nature of falls, as well as the effect of varying risk levels on fall frequency and overall spending.

Cost savings

Nymbl’s multimodal and clinically proven fall prevention platform easily scales and deploys across entire MA populations, driving significant cost savings in each of these risk categories.

If the above MA plan deployed Nymbl population-wide, the plan would see a $3.6M reduction in the medical cost of falls in the first 12 months of deployment. This is driven by Nymbl’s industry-leading enrollment rate of 10.2% (10,200 enrollees among a 100,000 MA population)

Nymbl helps margins in a time of revenue-related headwinds

By demonstrating impact in the first 12 months of deployment, Nymbl is an important tool for any MA plan seeking to improve its margins - and improve its memberships’ health and wellness. This analysis of the current fall-related costs and projected savings from Nymbl's program demonstrates a clear financial benefit for MA plans. By reducing the number of injurious falls, significant savings can be captured: millions over the next 12 months. With an impressive 3.18 ROI in the first year, Nymbl is necessary for reducing MA plans’ fall-related costs.

To learn more about how Nymbl can help stratify your member population by risk level and save your health plan millions, reach out to us, at info@nymblscience.com

1. CDC. Patient & Caregiver Resources. Older Adult Fall Prevention. Centers for Disease Control and Prevention (CDC), September 11, 2023 https://www.cdc.gov/steadi/patient.html.
2. 2023 National Population Projections Tables: Main Series. U.S. Census Bureau. Data & Maps, October 31, 2023. https://www.census.gov/data/tables/2023/demo/popproj/2023-summary-tables.html.
3. Ortman, Jennifer M., et al., An Aging Nation: The Older Population in the United States Population: Estimates and Projections. U.S. Census Bureau. Current Population Reports. May 2014, https://www.census.gov/content/dam/Census/library/publications/2014/demo/p25-1140.pdf.
4. Kelekar U, Das Gupta D, Shepherd JG, Sule AA. Risk Factors of Fall-Related Emergency Department Visits by Fall Location of Older Adults in the US. West J Emerg Med. 2021 Jul 19;22(4):988-999. doi: 10.5811/westjem.2021.2.49307. PMID: 35354005; PMCID: PMC8328180. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328180/.