See the High-Cost Claim
Before it Happens.

Before a person becomes high-cost, there are often signals.

A chronic condition is not being managed well.
A medication is not being taken consistently.
A screening is missed.
A person is moving between specialists without a strong primary care relationship.
A care plan is unclear.
A benefit is available, but the member does not know how to use it.
A small problem is allowed to become a serious one.

Converging Health is built to find those signals earlier.

We identify people whose health risk is rising, activate them through dedicated human support, and measure whether their risk profile and cost of care are moving in the right direction.

The best way to address high-cost claimants is to not have high-cost claimants.

How We Work: Identify, Activate, Measure

Identify the people whose risk is building

Whole Person Risk Score™ (WPRS™) is a predictive risk intelligence engine that identifies who is at risk and why, early enough to change the outcome.

CLINICAL DEPTH

WPRS combines diagnoses, medications, care quality gaps, social determinants, and more into a predictive score. No single factor tells the full story.

MODIFIABLE RISK

The model's FLARE component identifies engagement and behavior factors that can be changed. That focus on modifiable risk is what makes intervention possible.

INDIVIDUAL PREDICTION

Every score is built for a specific person, not a demographic segment. Sam and Sarah each get their own risk profile, so outreach is precise and timely.

WPRS identifies individuals for targeted intervention before they reach crisis. This intelligence drives high-value visits, care pathway interventions, and targeted activation. Risk migration across tiers is tracked over time, so program performance is measurable and defensible.

Activate high-risk members through MyPHA

Once the right people are identified, the next question is whether they will actually do the things that lower their risk. That is where MyPHA comes in.

MyPHA is Converging Health’s Personal Health Assistant service. A PHA is a dedicated human guide who provides proactive outreach, advocacy, navigation, coaching, and care coordination. The PHA helps members take the next right step. That may mean scheduling a primary care visit, closing a screening gap, understanding a medication, navigating benefits, coordinating between providers, finding a behavioral health resource, following up after a referral, or using a plan resource that the member did not know was available.

This is where risk begins to move. A high-risk member does not become lower-risk because they were identified in a report. Risk changes when the member is motivated, supported, and guided into better patterns of care. The PHA relationship is designed to create that movement.

Measure whether risk is actually going down

The real question is whether activation is changing the member’s risk profile and improving the economics of care. That is why Converging Health focuses on two key measures.

1. Is the Whole Person Risk Score improving?
The first measure is whether the member’s WPRS moves in the right direction after activation. This matters because WPRS reflects more than diagnosis severity. It also captures whether the member is more engaged, more connected to appropriate care, more consistent with follow-through, and less likely to experience avoidable deterioration.

When a PHA helps a high-risk member close care gaps, use primary care, manage medications, follow through on referrals, or become more active in managing their condition, the member’s risk profile should begin to improve. That improvement is measurable. The client can see whether high-risk members are becoming more managed, more engaged, and less likely to migrate into higher-cost categories.

2. Is the cost of care per risk point improving?
The second measure is whether the cost of care is decreasing relative to the amount of risk in the population. The goal is to manage risk more efficiently.

Converging Health helps members use available healthcare resources in a smarter and more coordinated way. That may mean better use of primary care, earlier intervention, stronger medication adherence, fewer unnecessary escalations, more appropriate specialty use, and better navigation of plan resources.

See the High-Cost Claim Before it Happens.