Solution: Healthcare

Provider Management

Case Management

Case management can be very effective at maximizing members' benefits, while simultaneously managing the managed care organization's costs. Whether case management is performed by the MCO, or by an independent case management organization, the first step is to identify where case management could be effective.

As a simple first step, identifying patients requiring lengthy acute care for specific conditions - AIDS or cancer - for example, would identify a good percentage of high-cost and complex cases. But moving a step beyond that, say identifying members with multiple chronic conditions, or co-morbidities, often involves a daunting amount of work.

The power of the Diver Solution to integrate and summarize data from multiple sources can help. Isolating those DRG's with the highest daily costs and highest number of discharges can be done with a few mouse clicks. Identifying patients with multiple chronic conditions takes just a few seconds more.

Use reports and analyses from Diver to:

• Understand the true cost effectiveness of case management programs.
• Determine exactly which medical costs - physician, pharmacy, acute care - are most impacted.
• Identify members who are potential candidates for a new or expanded case management program.

Disease Management

Though it can be very cost effective and bring improved quality of life, use of disease management is not always widespread. Often, it can be hard to assess the cost savings that accrue to the MCO. That said, it has been estimated by some health plans that 1% of their membership with multiple chronic conditions account for over a third of all inpatient days. However, as the population ages, that ratio will worsen further and the need to manage chronic illness pro-actively, rather than reactively, will become imperative.

Diver integrates and presents data from multiple sources, which empowers managed care organizations to easily compare the medical costs associated with different member populations. By tapping data on claims and utilization data from providers and pharmacies, for example, long-term cost trends for those in a disease management program and those in a control group can easily be compared. Not only that, but because every data element within a report or chart is "live", managers can immediately access detailed information, understanding which medications were used by which members, for instance.

Use reports and analyses from Diver to:

• Understand the true cost effectiveness of disease management programs.
• Determine exactly which medical costs - physician, pharmacy, acute care - are most impacted.
• Identify members who are potential candidates for a new or expanded disease management program.

Provider Profiling

Provider profiling is essential to both understanding outcomes and care quality, as well as discovering new opportunities for physician improvement or managing medical costs. In addition, it ensures that contractual standards or quality indicators are met. Yet, for some MCO's, the cost of collecting and manually collating data for profiling can out-weigh the benefits.

With the Diver Solution, data is integrated and summarized automatically. Summaries can be refreshed either on demand or automatically, whenever new data is available. Consequently, profiling becomes effortless, making it cost effective to drive quality improvements, enforce standards of care and ensure that physicians are rewarded promptly and correctly. And with the ability to dive into any summaries to see the detail data, you can easily move beyond simple performance measures, such as per-member-per-month costs. Profiling provider groups or independent practice associations, specialists and even hospital profiling can all be performed in this same way.

Not only can you provide profiling for managers and executives within your managed care organization, but Diver can help you grow member and employer satisfaction too. Using the same technology, you can readily provide information that you chose to your external stakeholders.

Care Quality

Managing care quality is essential for MCO's, from simple process-oriented HEDIS measures through to more complex outcomes-oriented metrics such as inpatient mortality, or re-admission rates. Care quality not only promotes member satisfaction, but helps to reduce medical costs too. Consequently, it's important to track success rates in screening for pneumococcal immunization, mammography, or cholesterol management, for example, as this should lead to cost savings in the long term. Further, detailed analysis of longitudinal data will quickly reveal which treatment plans and approaches deliver better outcomes and which are more cost effective overall.

Use Diver to:

• Gain deeper insight into HEDIS data.
• Track and analyze internal quality metrics or metrics unique to particular types of care - such as JCAHO core measures for acute myocardial infarction.