Goal: Reduce Inpatient Admissions

This article is part of a series of case studies—real stories of how managed care companies increased profits by using Summit Re’s resources to increase sales, decrease expenses, and manage claims. You may be aware of Summit ReSources' consultative case management and managed care programs, but what you might not know is that our Managed Care Specialist is available to perform an in-depth assessment of your own medical management practices and procedures. This helps you ensure that your medical management is effective and efficient, not only for the benefit of your bottom line, but it also may ensure optimal outcomes for your members.

Goal: Reduce Admissions

ABC Health Plan recently contracted with Summit ReSources’ Managed Care Specialist to perform an evaluation of its medical management department. The overall goal of the health plan was to shift away from intense inpatient utilization management and focus on outpatient case management. In other words, the health plan recognized the importance of implementing steps to prevent the inpatient admissions in the first place.

On-site Evaluation

An on-site evaluation included staff interviews and assessments of policies, procedures, processes, and computer systems. Some of the issues addressed included:

• Are the health plan’s policies and procedures consistent with the NCQA standards?
• Are staffing patterns consistent with national benchmarks?
• What is the most cost-effective way to perform utilization management?
• What are appropriate outcome measures for medical management?
• What key features should be included in a disease management program?
• Which members should be referred for disease and case management?
• What are appropriate measures for return on investment for disease management and case management?
• What key features should be included in a predictive model?

Recommendations

Recommendations were made related to maintaining only the utilization management process that would provide the greatest clinical and financial value to the organization.

Since ABC Health Plan did not have a well-developed case management program, specific recommendations for the development of such a program were provided, including but not limited to, examples of case management referral triggers, screening tools, acuity measures, and return-on-investment documentation.

Post evaluation, there were several additional phone conferences regarding implementation of the recommendations.

The feedback from ABC Health Plan was that the assessment and recommendations were “crucial” and “most helpful” in moving the process forward to meet the overall goals of the organization.

Summit ReSources is available to provide an evaluation of your medical management program. Whether you are a small or large managed care organization, eliciting an outside evaluation of your medical management efforts can be beneficial. Summit Re works with efficient, cost-effective health plans, but most understand the need for continual improvements in medical management given the rapid changes in health care.

Five essentials for evaluating predictive models

Predictive modeling uses your vast store of information to forecast future needs for medical resources. By becoming a knowledgeable purchaser and user of predictive modeling services, you can enjoy a return on your investment in the areas of care management, underwriting and benefit design.

Key Factors for RFP

There's been an explosion of predictive modeling services, each with different methodologies and technology designs. Ineffective predictive modeling— through either poor models or data—wastes your valuable resources and may have a negative impact on your members. However, by understanding how to assess the offerings and apply the technology once you have purchased it, predictive modeling can realize the promise of using information to significantly improve value in health care. The following factors can be used in a Request for Proposal (RFP) to help you select a vendor:

Accuracy

Always ask for the model's R-squared measurement, the commonly accepted measurement of a predictive modeling solution's accuracy. Reliable vendors will know their R-squared measurement.

Vendors should be able to demonstrate both the sensitivity and specificity of their solutions, especially for case management programs. High sensitivity indicates positive predictive value: an ability to identify most of the people who would benefit from a care management intervention. Specificity or negative predictive value is the ability to limit the number of false positives or people who would not benefit from a care management program. Sensitivity and specificity are important so you can assign resources where they're needed most.

Transparency

Transparency means the ability to differentiate among the data points. For care management programs, transparency means clinicians can look underneath the risk scores to the level of individual claims so they can devise appropriate interventions. A risk score is not particularly helpful for care management nurses; they need a way to understand what's driving the risk. To this end, member profiles should include a listing of all episodes of care and the key services involved in their treatment.

To evaluate transparency in your RFP, ask whether the model is a rules-based or neural net solution. In general, you should look for rules-based models, because they match data patterns to clear clinical rules that identify such things as the disease, type of episode, co-morbid conditions, and drug treatments. In a good rules-based model, you can easily identify these risk markers.

In contrast, neural net or so-called black box algorithms are not clinically based and are technically complicated, so you have to possess real data mining expertise to understand how a specific risk score has been compiled. This robs clinicians of many of the advantages that predictive modeling should deliver for care management. Black box algorithms also make it difficult for you to check the validity of the model.

Interoperability

Your RFP should ask whether the vendor supports your relevant database technologies, so they can load the data quickly and reliably into their model's data mart. You should also ask if supporting databases will be exported to your care management, underwriting, and actuarial applications.

Another key question is how the model defines and groups care— by procedure, diagnosis, or episodes of care. Using fully fleshed-out episodes of care results in better predictions since the groups are clinically homogeneous. This approach takes into account all of an individual's underlying clinical factors, not simply a diagnosis or severity indicator.

Supports operational needs

The solution selected must adapt to your operational issues and must generate predictions as often as your business needs dictate. Also, the data used in the solution must be fresh, reliable, and accessible. In particular, it should be refreshed at least monthly to be available for client renewals.

Finally, the solution must be flexible enough to use the data that is available, e.g., medical only, pharmacy only, medical and pharmacy combined. It should also be able to incorporate emerging data sources, such as lab results.

Industry credibility

One of the most obvious markers of industry credibility is market penetration. The RFP should probe whether others use the solution and if they will speak to its value.

Because predictive modeling is changing and improving at a rapid rate, credibility is not just rooted in the solution itself, but in the ongoing support the vendor offers. Upgrades and support require a team that fully understands not just the technology, but also how health care works. The RFP should check whether the support offered includes an integrated team that brings together IT, clinical, actuarial, and underwriting experts.

The information in this article is subject to change without notice. This article contains proprietary information, which is protected by U.S. and international copyright. All rights are reserved. No part of this article may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, without the express written permission of Ingenix, Inc. Copyright 2006 Ingenix, Inc.

Summit ReSources: Make It Your Managed Care Resource

Summit Re established its own managed care department, Summit ReSources, to give you  access to a comprehensive portfolio of services, specifically designed to reduce costs while improving quality of care. The primary goal of Summit ReSources is to be your managed care resource. Consultative Case Management

We are available for consultative case management which includes, but is not limited to, assessment and recommendations regarding utilization, disease and case management programs, access to external managed care vendors at preferred prices, catastrophic case discussions, specialty pharmacy issues and out of area solutions. There is no additional cost for accessing our consultative case management service.

Educational Resources

Summit ReSources has access to a variety of educational opportunities and information about medical management. As information becomes available, we share it with you.

Portfolio

A portfolio of services has been negotiated to help you manage your claims. They include:

Transplant Management

National PPO Network

Non-network Claims Management

Catastrophic Injury/Illness

Recovery/Coordination of Benefits

Neonatal Intensive Care Management

Predictive Modeling

Chronic Disease Management

Summit ReSources was created in September of 2004.  Debbie Stubbs is the primary contact and Laura Pearce is Debbie’s backup for managed care issues.  You will find more information about Summit ReSources on our website at www.summit-re.com/managedcare.asp.

Summit ReSources Portfolio of Services

As a result of the survey and client conversations, the following Summit ReSources portfolio of services was structured.  Each vendor underwent a stringent due diligence process. An onsite visit to the primary facility providing the service was part of the process for the majority of the vendors. If you would like to learn more about any of the programs or have any questions, please contact Debbie Stubbs or Laura Pearce.   If there are other programs you think we should consider adding to Summit ReSources, please let us know. Transplant Management

United Resource Networks (URN)

URN offers consulting expertise and access to over 100 of the nation's most prestigious medical centers specializing in organ and tissue transplantation. Specialized Physician Review services are also available, whereby our customers can obtain independent, expert medical opinions of the appropriateness of proposed transplants for     specific members and in the area of congenital heart disease.

URN also has a Congenital HeartDisease program, which includes   access to a network of facilities that excel in the treatment of congenital heart disease (CHD).  The CHD programs complement the heart transplant expertise found within the URN transplant network.

Claim Recovery

Health Decisions, Inc. (HDI)

HDI specializes in benefit management services that produce a 3:1    return on investment within 12 months, while leaving current coverage intact.  HDI provides claim recovery and enrollment support services.

Disease Management

See related article (click here).

National PPO Network

GlobalCare, Inc.

By offering access to a 24-hours-a-day, 7-days-a-week Medical Help Desk, as well as through relationships with over 100 PPO networks andnegotiators, GlobalCare allows your members to have medical assistance and network access anywhere in the United States and around the world.

Predictive Modeling

Integrated Healthcare Information Services, Inc. (IHCIS)

Impact Pro is IHCIS’s industry-leading, rules-based predictive modeling tool that produces a measure of future relative risk, a prediction of future health care costs,  relative risk for an inpatient admission and the probability of one or more admissions for each   enrolled member of a health plan. These measures of risk can be used in medical management and have financial, actuarial and underwriting     applications. Impact Pro is used by leading health plans and clinicians across the United States, serving more than 30 million Americans.

Non-Network Claims Management

Global Claim Services (GCS)

GCS specializes in clinical and financial claims reviews, offering a personalized, process-oriented approach for out-of-network medical claims and fee negotiations for inpatient and out-patient facilities, professional services and ancillary fees.

Neonatal Intensive Care Management

See related article (click here).

Catastrophic Illness and Injury

Paradigm Health Systems, Inc,

The highly skilled staff specializes in management of a variety of catastrophic medical events, such as brain injuries, spinal cord injuries, complex burns and severe trauma.