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      Reference this HealthAnalytIQ User Guide for any questions you have about this platform.

      Identifying and Stratifying Members by Risk

      Utilization Cost – A high-level overview of utilization across the entire organization as it relates to risk, cost, patient encounters, and more. Sophisticated statistical modeling is used to forecast costs across risk categories 12 months into the future before those costs are incurred. Insights into costs associated with members and their families are presented for review and action.

      High-Cost Groups – This high-level dashboard displays a complete list of either individual members or groups within a health plan ranked by their medical loss ratio (MLR). A user can quickly and visually analyze correlations between the MLR, claims paid, premiums received, profit/loss, and 12-month predicted costs and overall risk status for each listed member or group. A robust drill down capability shines more light on the types of claims being paid, where those claims are being incurred, and more, for any time period selected by the user.

      Disease Management – This dashboard is designed to identify members eligible for various disease management programs across all chronic conditions. Program management flags are built into worklists to allow care coordinators easily filter patients by the care management and disease management programs they are currently enrolled in, and quickly identify patients eligible for but not enrolled in appropriate care management programs. The dashboard is subdivided into the following categories (tabs):

      • Disease Prevalence – This is a graphical representation of the prevalence of diseases and chronic conditions within an entire population, sorted by most prevalent to least prevalent conditions. Included below condition is a listing of patients who have been identified as having that condition, with the ability to drill down to individual patient profiles.
      • Pediatric Risk Spheres – The following reports are included on this tab: Overall Risk Score, 30-day Readmissions Risk, Probability of Becoming Persistent High Users, Probability of Extended Hospitalization, and Probability of ICU Hospitalization for the entire pediatric population.
      • Adult Risk Spheres - The following reports are included on this tab: Overall Risk Score, 30-day Readmissions Risk, Probability of Becoming Persistent High Users, Probability of Extended Hospitalization, and Probability of ICU Hospitalization for the entire adult population.
      • Global Patient Identification – This worklist allows for easy identification of patients eligible for care management and disease management programs. Identification can occur by programs patients are currently enrolled in, their chronic conditions, or risk categories. Detailed clinical profiles are available for each patient, including contact information.

      Risk Spheres – This dashboard provides analyses of stratified patient populations based on the ACG risk stratification methodology developed at Johns Hopkins. Risk Spheres classify patients into Healthy, Low, Moderate, High, and Very High risk categories. Risk Spheres also present comprehensive, patient-specific predictive risk profiles. The dashboard is subdivided into the following categories (tabs):

      • Pediatric Risk Spheres – The following reports are included on this tab: Overall Risk Score, 30-day Readmissions Risk, Probability of Becoming Persistent High Users, Probability of Extended Hospitalization, and Probability of ICU Hospitalization for the entire pediatric population.
      • Adult Risk Spheres - The following reports are included on this tab: Overall Risk Score, 30-day Readmissions Risk, Probability of Becoming Persistent High Users, Probability of Extended Hospitalization, and Probability of ICU Hospitalization for the entire adult population.
      • All Conditions Risk Strata – This is a comprehensive, unified breakdown of risk categories for all disease conditions present in the patient population, including diabetes, hypertension, asthma, CHF, and more. Conditions with the most high-risk patients are visually identifiable for quicker analysis.
      • Patient Profile – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drill down path from any dashboard or report.

      Risk Matrix – This Gartner quadrant-style set of analytical dashboards presents correlations between claims and premiums and highlights the interplay between statistical probabilities, risk profiles, claims paid, and premiums collected. Statistical probabilities such as Likelihood of Inpatient Hospitalization, Extended Hospital Stay, Unplanned 30-Day Readmission, and more, are weighed against claims, premiums, and risk scores of individual members or groups and plotted on the quadrant for visual analysis.

      Probability Profile – A report that profiles the statistical probability of both individuals and groups to experience adverse, cost-related outcomes such as the likelihood to be readmitted to the hospital within 30 days of discharge, likelihood of becoming a persistent user of healthcare resources, probability of being hospitalized due to an injury, probability of ICU hospitalization, and more.

      Risk Trends – A retrospective “mover” dashboard that tracks and trends changes in individual member risk over a period of time. Member risk scores and changes in risk category are weighed against changing predictions on their likelihood to display certain cost and utilization characteristics on an ongoing, month by month basis. Changes in health status as well as the development of new medical conditions are highlighted chronologically and graphically along with costs associated with those changes. The dashboard is subdivided into the following categories (tabs):

      • Risk Trends – This is a graphical display of the variance in risk scores and risk status of each member over a period of time. Users can trend risk in either up or down direction, enabling the review of members that are responding favorable or negatively to wellness program and other initiatives.
      • Risk Chronology – A graphical, chronological display of changes in the risk score of each member on a month to month basis along with pharmacy-derived care gaps that are associated with that individual.
      • Predictive Risk Profile – A graphical, chronological display of changes in the predictive risk profile of each member on a month to month basis based on the ACG-derived risk adjustment and stratification done for each foregoing month.

      Provider Profile – This dashboard presents a comparison of the risk profile of provider panels, including weighted risk scores for each provider’s panel, cost analyses, and detailed patient profiles. These detailed provider profiles are presented across multiple specialties for all chronic conditions. The dashboard is subdivided into the following categories (tabs):

      • Provider Profile – This tab presents a comprehensive risk profile for providers and shows the level of overall risk represented within each provider’s panel. Patient listings and cost analyses are presented as well, all broken down and filterable by all available disease conditions that are treated by each provider.
      • Patient Profile – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drill down path from any dashboard or report.

      Health Plan Management and Employee Benefits Administration

      Premium Dashboard – This dashboard analyzes the ongoing monthly premiums collected by the health plan(s) in any given plan year, correlates them to the medical, pharmacy, dental and vision claims costs being paid out during the same period of time, and provides 12-month projections of risk and cost increases as well as recommendations for possible premium increases where applicable.

      Renewals – Geared toward organizations that manage open enrollments, this spreadsheet-style dashboard comes in handy during renewals and provides information on each group such as total medical, Rx, and vision costs, total paid premiums, QI costs, MLR, TLR, and admin fees. Built-in criteria allow the modeling of group rates, risk bands, and other baseline scenarios prior to each renewal.

      Stop Loss Report – This administrative dashboard utilizes a client-specified deductible amount (such as $500K) and deductible threshold (such as 50%) for a health plan to analyze individuals and groups that have met or exceeded the threshold that triggers individual or aggregate stop-loss coverage. Deductible amount and threshold are adjustable on the fly by the user. Details such as family relationship, total claims amount, diagnoses, procedures, and medication cost are displayed for those that meet the criteria.

      Plan Manager Dashboard – Another administrative dashboard that enables the ongoing monitoring of medical, Rx, dental, and vision claims (weekly, monthly, quarterly or semi-annually) at the group level. Includes metrics such as total count enrollees in each plan, coverage status, family relationship, total claims cost, and more.

      Total Cost – This set of reports provides detailed insights into the medical, pharmacy, dental and vision costs across the health plan(s) as well as drill down to the places of service where the individual members and employer groups receive care and medical services most often.

      Employee Map – An offshoot of the Population Mapping application, this interactive map enables plan managers and other decision makers to view employees and dependent information and statistics by ZIP Code Clusters, City, County, etc. on a live map. The map can be overlaid with additional data such as risk scores, claims cost, premiums, utilization metrics, and more.

      Managing Utilization and Associated Costs

      Utilization Cost – This dashboard is a high-level overview of utilization across the entire population as it relates to risk, cost, patient encounters, and more. Sophisticated statistical modeling is used to forecast costs across risk categories 12 months into the future before those costs are incurred. Insights into costs associated with individual members (employees) and their families are presented here. The dashboard is subdivided into the following categories (tabs):

      • Utilization Summary – This tab displays reports showing Utilization Cost Summary, total, average monthly, and forecasted (predicted) costs broken down by risk category buckets (Non Users, Healthy, Low, Moderate, High, and Very High). Also includes patient demographics, Patient Encounters, planned and unplanned utilization stats, and more.
      • Employee Utilization – This tab displays tables and graphs showing a breakdown of the patient population by member type, i.e. employee, spouse, or dependent. Also displays a graphical breakdown of places where each group receives the most medical services.
      • Medical Plan Utilization - This tab displays tables and graphs showing a breakdown of the patient population by medical plan, i.e. employee, spouse, or dependent. Also displays a graphical breakdown of places where members of each medical plan receive the most medical services.
      • Disease Prevalence – This is a graphical representation of the prevalence of diseases and chronic conditions within the entire population, sorted by most prevalent to least prevalent conditions. Included below condition is a listing of patients who have been identified as having that condition, with the ability to drill down to individual patient profiles.
      • Hospitalization and Readmissions – This is a graphical representations of Members at Risk of 30-day Unplanned Readmissions and Members at Risk of Inpatient Admission within 6 Months for all available disease conditions and broken down by age groups from newborn to the elderly.
      • Patient Profile – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drilldown path from any dashboard or report.

      ED and Urgent Care Utilization – This dashboard provides a look at Emergency Department and Urgent Care utilization patterns by individual members and their families. This dashboard includes a useful “Frequent Flier” list of the highest users of these high-cost services as well as their geographical locations and clinical profiles. The dashboard is subdivided into the following categories (tabs):

      • Utilization By Claims – This tab shows graphs of Patients and Claims by Age, Patients and Claims by Claim Status, and Patients and Claims by Condition, broken down by member type (employee, spouse, or dependent).
      • Utilization by Condition – This tab shows Visits by Month, Patients and Claims by Procedure, and Patients and Claims by Condition, broken down by member type (employee, spouse, or dependent).
      • Frequent Fliers – A listing of members who have been identified as “Frequent Fliers” to either the ED or Urgent Care centers as well as their associated costs. Also shown is a line graphs of ED and Urgent Care Visits by Day of the Week, which can be useful for anticipating high utilization periods.
      • Patient Profile – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drill down path from any dashboard or report.

      Case Management – The case management dashboard is designed to automatically identify members eligible for enrollment into appropriate case management programs based on a defined set of criteria. Detailed patient profiles on all identified members are available for review from each area. The dashboard is subdivided into the following categories (tabs):

      • High Medical Needs – High Medical Needs patients are identified as members that have the frailty flag turned on, have at least one hospital dominant morbidity type, and have at least five chronic conditions. In addition, by specifying a total cost band less than eight (8), only patients with prior costs below the 95th percentile are included, which potentially provides a subset of patients not already enrolled in a case management program.
      • Emerging Risk – This is a group of patients that are lower cost this year (based on a Total Cost Band < 7), but predicted to be high cost next year (based on a Rank Probability High Total Cost > 0.4). Patients with ESRD, cancer, transplant, and HIV markers have also been excluded, as typically patients with these conditions will already have been identified for complex case management programs.
      • Potential Home Health / DME Needs – The frailty flag represents a set of diagnosis codes that describe clinically frail individuals (greater than or equal to 18 years of age) and are highly associated with marked functional limitations. Frailty concepts included are Absence of Fecal Control, Decubitus Ulcer, Dementia, Difficulty in Walking, Fall, Loss of Weight, Major Problems of Urine Retention or Control, Malnutrition and/or Catabolic Illness, Severe Vision Impairment, and Social Support. The presence of this marker may be an indicator of support needs, such as home care, DME, transportation assistance, etc. Nursing Service is a binary flag (0 = No, 1 = Yes) to indicate that a patient has used services in a nursing home, domiciliary, rest home, assisted living, or custodial care facility during the observation period. By setting Nursing Service = 0 in the following figure, patients who are receiving services in a nursing facility are excluded, as these patients are likely receiving the necessary assistance with their activities of daily living. Patients with cancer, ESRD, transplant or HIV are also excluded, as typically patients with these conditions will already be in a case management program. Finally, the chronic condition count has been limited to patients with a maximum of five chronic conditions, primarily to show that this may identify a different group of patients than were already identified as high medical need patients.
      • High Risk Pregnancy – Pregnancy without delivery is an important marker for predicting future resource use and has been used in every version of the ACG Predictive Models. The availability of date and procedure information provides the opportunity to further refine this important marker. If date of service is available, this marker will consider the order of events to capture the latest pregnancy status during the observation period in the event that a pregnancy does not continue to delivery or the patient experiences multiple pregnancies during the year.
      • Severe and Persistent Mental Illness – Aggregated Diagnosis Groups (ADGs) provide a good foundation for identifying members with severe and persistent mental illness. ADGs classify diagnoses into a limited number of clinically meaningful, but not disease-specific, morbidity groups. Each ADG is homogenous with respect to specific clinical criteria and their demand on healthcare services. ADGs are highly predictive of current and future resource use and take into account the expected duration of the condition, the implied severity of the condition, the level of diagnostic certainty, the etiology of the condition, and whether or not specialty care services are likely to be used. Two ADG categories, ADG 24 (Psychosocial: Recurrent or Persistent, Stable) and ADG 25 (Psychosocial: Recurrent or Persistent, Unstable) are used to assess the level of mental health disease burden within the population. Using both ADGs together may result in the identification of a large number of candidates for a behavioral health management program, but may not isolate the group of members that would most benefit from program interventions. A subset of the psychosocial EDCs (e.g. Schizophrenia and affective psychosis, Bipolar disorder, Major depression, etc.), the predictive risk scores and/or the Hospital Dominant Morbidity Types are used to further stratify the population. Frequently individuals have both complex medical and behavioral health conditions, and determining which morbidity is driving the overall healthcare needs may be unclear.

      Rx Management – This is a comprehensive Rx Management dashboard for analyzing pharmacy patterns, identifying pharmacy-related care gaps, and reviewing detailed patient Rx profiles on all members of the population that take any type of medications. The dashboard is subdivided into the following categories (tabs):

      • Rx Summary – This tab displays summary statistics on a variety of population-wide metrics, including a breakdown of patients by the currently treated chronic conditions, drug classes, and average drug costs.
      • Treated Conditions – This tab shows a breakdown of all treated chronic conditions by gender as well as associated Total Rx costs. A patient listing is available for each condition, with drill down to detailed patient Rx profiles.
      • Drug Prevalence – An analysis of all drug classes prevalent throughout the population, broken down by gender and total cost, and sorted in order of magnitude by patient volume and cost. A patient listing is available for each drug class, with drill down to detailed patient Rx profiles.
      • Drug Gaps by Condition – An analysis of Rx gap days and max gap days occurring throughout the population, broken down by treated condition, and sorted in order of magnitude by patient volume and gap days. A patient listing is available for each drug class, with drill down to detailed patient Rx profiles.
      • Drug Gaps by Drug Class – An analysis of Rx gap days and max gap days occurring throughout the population, broken down by drug class, and sorted in order of magnitude by patient volume and gap days. A patient listing is available for each drug class, with drill down to detailed patient Rx profiles.
      • Drug Gaps by Condition – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drill down path from any dashboard or report.
      • Care Gaps – This tab enables quick identification of care gaps based on medications and treated conditions. Users can quickly identify patients with various chronic conditions who are not currently taking any meds for those conditions or who are not taking appropriate meds to treat all chronic conditions that are present. A patient listing is available for each monthly data point, with drill down to detailed patient Rx profiles.

      Management Programs – This care management dashboard is designed to automatically identify members eligible for enrollment into appropriate management programs based on a defined set of criteria. Detailed patient profiles on all identified members are available for review from each area. The dashboard is subdivided into the following categories (tabs):

      • Medication Therapy Management – The ACG System pharmacy-based predictive models provide an excellent means of finding the population of individuals eligible Medication Therapy Management (MTM). This program is designed to improve medication adherence, patient safety and quality. The programs typically focus on promoting beneficiary education and counseling, increasing enrollee adherence to prescription medication regimens, and of detecting adverse drug events and patterns of over-use and under-use of prescription drugs. These outreach programs should target individuals with multiple chronic conditions, such as, but not limited to, diabetes, asthma, hypertension, disorders of lipid metabolism, and congestive heart failure, who are taking multiple covered Part D Drugs and who are identified as likely to incur annual costs above a specified threshold.
      • Utilization Management - Hospitalization – The criteria used on this tab identifies patients with a high likelihood of hospitalization within the next 12 months, who do not have evidence of active cancer treatment and are not receiving dialysis. Patients are identified with prior costs below the 95th percentile, which indicates patients that may not already be included in a care management program.
      • Utilization Management – High Utilization – To identify patients that are at risk for future high utilization, it is reasonable to assess the Coordination Risk in conjunction with previous utilization. Two utilization markers to consider are the Unplanned Inpatient Hospitalizations count and the Readmissions 30-day count. The Unplanned Inpatient Hospitalizations count is a subset of the inpatient hospitalizations count with exclusions for planned admissions. A planned admission is defined as either a definitively planned procedure, such as rehabilitation services, chemotherapy and transplants or a potentially planned procedure, such as hip replacements, cardiovascular procedures and other inpatient surgical treatments without evidence of acute complications such as infections, burns or injuries. Any inpatient hospitalization that cannot be identified as definitively or potentially planned is considered unplanned. The Readmissions 30-day count is a subset of the All Cause Inpatient Hospitalizations count. The presence of this count indicates, regardless of cause, the identified admission occurred within 30 days of a previous admission.
      • Utilization Management – Emergency Room – The criteria used on this tab identifies patients who have no evidence of seeing a provider on an ambulatory basis (and hence, also no generalist involved in their care), but who have multiple ER visits (greater than two). The criteria are further refined by excluding patients with Expanded Diagnosis Clusters (EDCs) that are frequently, and appropriately associated with ER visits. Of primary concern are patients that do not have any follow-up ambulatory visits and therefore, probably are not receiving any ongoing management and education about their conditions.
      • Metabolic Syndrome and Pre-Diabetes Risk – Metabolic Syndrome is a combination of medical disorders (Hypertension, Dyslipidemia, and Obesity) that, when present, increase the risk of Cardiovascular Disease and Diabetes. This tab provides a method to identify patients with evidence of Hypertension and Disorders of Lipid Metabolism based on the condition markers, as well as evidence of Obesity either through the presence of a medical diagnosis or a weight control medication, but with no evidence of Diabetes already being present. This is a group of patients that may benefit from targeted, pro-active interventions aimed at preventing, or at a minimum, delaying the onset of more serious medical conditions. This group of patients may warrant further assessment of lifestyle choices, but may also benefit from a review of medications being taken to control their Hypertension and high cholesterol, and whether they are adherent with filling those prescriptions.

      Analyzing Claims and Payments

      Medical Claims– This dashboard presents a series of reports and analyses revolving around claims, payments, and denials and presented across multiple dimensions such as age, gender, provider, specialty, Date of Service (DoS), condition, service location, revenue code, length of stay (LOS), and more. The dashboard is subdivided into the following categories (tabs):

      • Large Claims Report – A comprehensive, deep dive into claims activity involving user-defined criteria for Large Claims. Provides drill down into the number of claims occurring per individual or group, claims detail such as primary and secondary diagnoses, procedures, and place of service for any selected time period. Also shows premiums collected over the same period as well as profit and loss indicators per group.
      • Large Claims Watchlist – This tracking watchlist is fully customizable to a client’s specific definitions but generally allows the ongoing monitoring of claims activity meeting certain set criteria, such as groups with claims exceeding $50K, members with individual claims exceeding $25K, groups or individuals with total Rx cost exceeding 25% of their paid premiums or other client-specified monitoring criteria.
      • Claims Profile – A series of analyses with regard to claims, payments, and denials presented across multiple dimensions such as age, gender, provider, specialty, condition, service location, revenue code, length of stay, and more. Also provides a focus on large claims as defined by the client.
      • ED and Urgent Care Utilization – A detailed look at Emergency Room and Urgent Care utilization patterns by individual members and groups. This dashboard includes a “Frequent Flier” list of the highest users of these high-cost services as well as their geographical locations and clinical profiles.
      • Special Cases – A comprehensive look at high-cost groups that may require more proactive case management. Groups such as maternity patients, frail patients, and members with unusual cases are profiled and presented for care coordination and case management.
      • Payment and Claim Status – Reports include Average & Total Payments by Specialty and Condition, Claim Status by Condition and Specialty, and Claim Status by Total Payment and Age.
      • Claims Paid vs. Rejected – Specialty – Reports include Paid and Rejected Claims by Specialty and disease condition, broken down into years, quarters, or months as needed.
      • Claims Paid vs. Rejected – Condition - Reports include Paid and Rejected Claims by disease condition, broken down into years, quarters, or months as needed.
      • Claims Paid vs. Rejected – Provider – Reports include Claims and Case Volume by Provider Specialty and Payments broken down by Provider, years, quarters, or months as needed.
      • Payments by Condition – Includes the Average & Total Payments by Condition report broken down by years, quarters, or months as needed.
      • Payments by Revenue Code - Includes the Average & Total Payments by Revenue report broken down by years, quarters, or months as needed.
      • Revenue Code Analysis - Reports include Number of Patients and Claims by Revenue Code, Total Paid Amount by Age and Revenue Code, Total Paid Amount by Gender and Revenue Code, and the % of Patients by Claim Status and Revenue Code.
      • Payments by Specialty - Includes the Average & Total Payments by Specialty report broken down by years, quarters, or months as needed.
      • AR Analysis – General - Reports include Days from DoS to Payment by Condition, Days from DoS to Payment by Provider Specialty, Days from DoS to Payment by Revenue Code, and Days from DoS to Payment by Age and Average LOS, all filterable by Service Year and Service Month.
      • AR Analysis – Payments - Reports include Days from DoS to Payment by Condition, Days from DoS to Payment by Age and Average LOS, Days from DoS to Payment by Revenue Code, and Days from DoS to Payment by Provider Specialty, broken down by years, quarters, or months as needed.
      • AR Analysis – LOS - Reports include Days from DoS to Payment by Average LOS, Days from DoS to Payment by Age and Average LOS, and Length of Stay by Condition and Place of Service.

      Pharmacy Profile – A comprehensive profile of pharmacy costs and utilization based on coded Rx data for injectable drugs. Analyses are presented by dimensions such as provider specialty, place of administration, AHRQ disease and procedure groups, age, lists of most utilized drugs, and more. The dashboard is subdivided into the following categories (tabs):

      • Rx Mapping – This is an interactive mapping application that enables the geographical tracking of patients by their prescriptions, prescribers, and treated chronic conditions. It also shows the prevalence of drugs and drug classes by ZIP code and city, prescription writing patterns of prescribers, and pharmacy utilization.
      • Pharmacy Profile – A profile of pharmacy costs and utilization based on coded Rx data for injectable drugs. Analyses are presented by dimensions such as provider specialty, place of administration, AHRQ disease and procedure groups, age, lists of most utilized drugs, and more. This tab contains the following reports: Rx by Patient, Rx by Age and Gender, and Rx by Age Range (Children 0 – 17; Young Adults 18 – 39; Middle Age Adults 40 – 64; and Senior 65+).
      • Rx Analysis – This high-level dashboard illustrates trends in Total Pharmacy Cost over a chosen time period. It reflects the percent increase or decrease in pharmacy spend month over month for individual members or groups within any given population. The dashboard can be customized to reflect pharmacy costs over a certain dollar threshold and includes the ability to drill down to high-cost drugs.
      • Rx Management - A comprehensive pharmacy management dashboard for analyzing pharmacy patterns, identifying pharmacy-related care gaps, and reviewing detailed patient Rx profiles on all members of the population that are on any type of medications.
      • Rx Costs - This tab contains the following reports: Rx and Total Cost and Rx and Average Cost, both filterable by Age Range, Condition, Service Year, and Service Month.
      • Rx by Specialty and Location - This tab contains the following reports: Rx by Specialty and Rx by Place of Service, both filterable by Age Range, Condition, Service Year, and Service Month.
      • Rx by Provider and Payment - This tab contains the following reports: Rx by Provider and Rx Payments by Provider, both filterable by Age Range, Condition, Service Year, and Service Month.
      • Rx by AHRQ Groups - This tab contains the following AHRQ-related reports: Rx by AHRQ Disease Group and Rx by AHRQ Procedure Group, both broken down into their respective AHRQ categories and classifications and filterable by Age Range, Service Year, and Service Month.
      • Rx by Age – This tab contains the Rx by Average Age and Rx. The report sorts the most prescribed medications by the average age of users on those medications.

      Developing Geo-access Strategies

      Mapping Application – This is an interactive mapping application that enables the geographical tracking of disease prevalence by condition, age, gender, provider specialty, and more. The map can be configured to display any number of metrics and can be customized to fit client requirements. The dashboard is subdivided into the following categories (tabs):

      • Population Mapping – This is a highly configurable “live” map that can display any number of metrics, including geographical disease prevalence, provider panels, and more. The map is filterable by any number of attributes such as Age, Condition, Gender, Service Period, and more.
      • Condition by Age and Claims – This tab contains the following reports: Patients and Claims by Age Group, Length of Stay by Condition and Place of Service, and Number of Inpatients / Outpatients and ED Visits, broken down by age ranges, condition, and more.
      • AHRQ Disease Distribution - This tab contains the AHRQ Disease Group by Age and Total Payment report which is filterable by attributes such as Provider, Revenue Code, and Service Period.
      • Payments by Age and Claims - This tab contains the following reports: Patients by Age Group and Claims by Age Group, both filterable by Age Range and Condition and broken down into Service Years.
      • AHRQ Procedure Distribution - Contains the following AHRQ Procedure Group-related reports: % of Patients by Age and CPT Procedure, Paid Amount by Age and Procedure, % of Patients by Age and Procedure, and Average LOS by Age and Procedure, broken down by AHRQ and CPT procedures and filterable by Condition, Revenue Code, and Service Period.
      • AR Analysis - This is another highly configurable, “live” map that displays the following metrics: Days from DoS to Payment by ZIP Code, Days from DoS to Payment by City, and Days from DoS to Payment by Age. The graphs are sorted to show which geographical areas represent the longest days in AR.

      Rx Mapping – This is an interactive mapping application that enables the geographical tracking of patients by their prescriptions, prescribers, and treated chronic conditions. It also shows the prevalence of drugs and drug classes by ZIP code and city, prescription writing patterns of prescribers, and pharmacy utilization. The map can be configured to display any number of additional metrics and can be customized to fit specific client requirements. The dashboard is subdivided into the following categories (tabs):

      • Patient Mapping – This tab enables the geographical tracking of patients by their prescriptions, prescribers, age group, and treated chronic conditions. Drill down capability is available down to city and ZIP code. A search functionality enables a user to look up individual patients by name.
      • Prescriber Mapping – This tab enables the geographical tracking of prescribers by the drugs and drug classes that they prescribe as well as by treated conditions of their patients. Drill down capability is available down to city and ZIP code. A search functionality enables a user to look up individual prescribers by name.
      • Pharmacy Mapping – This tab enables the geographical tracking of pharmacy utilization by patients based on the prescriptions they are filling as well as by their treated conditions. Drill down capability is available down to city and ZIP code. A search functionality enables a user to look up individual pharmacies by name.

      Employee Map – An offshoot of the Population Mapping application, this interactive map enables plan managers and other decision makers to view employees and dependent information and statistics by ZIP Code Clusters, City, County, etc. on a live map. The map can be overlaid with additional data such as risk scores, claims cost, premiums, utilization metrics, and more.

      Care Management and PHM

      COVID-19 Surveillance – This new and very timely dashboard was designed during the 2020 pandemic to enable organizations of all types and sizes such as employers, health plans, public school districts and consortiums, and other fiduciaries be able to quickly identify members who are most vulnerable to the current COVID-19 pandemic. Following World Health Organization (WHO) guidelines on COVID-19 and its characteristics, this new dashboard utilizes proprietary, sophisticated risk stratification algorithms and working in conjunction with the highly regarded Johns Hopkins ACG® clinical grouper to identify and stratify those within any given population who are at greatest risk of serious illness, complications, and death from COVID-19.

      Case Management - A dashboard designed to identify members eligible for case management intervention across an entire population. Patients with multiple chronic conditions, high medical needs, emerging risk, home health needs, and others such as frail individuals, members with pressure ulcers, and those that have experienced falls or unexplained loss of weight are easily identified in a worklist and flagged for case management.

      Disease Management - A dashboard designed to identify members eligible for various disease management programs across all chronic conditions. Program management flags are built into worklists to allow care coordinators to easily filter patients by the care management and disease management programs they are currently enrolled in, and quickly identify patients eligible for but not currently enrolled in appropriate care and disease management programs.

      Management Programs - This dashboard automatically identifies members eligible for Medication Therapy Management (MTM), Utilization Management, Metabolic Syndrome and Pre-Diabetes Risk across an entire population. Patients with multiple chronic conditions, high utilization of medical resources, multiple inpatient, outpatient and ED visits, and others with conditions such as hypertension, dyslipidemia and obesity etc. are easily identified in a worklist and recommended for appropriate management programs.

      Undiagnosed Hypertension Surveillance – This hypertension surveillance dashboard was developed to identify patients whose systolic and diastolic blood pressure readings place them in one of the categories for hypertension based on an automated review of the medical record, but whose disease is currently undiagnosed by a physician. The Hypertension Surveillance Dashboard uses generally accepted guidelines from the American Heart Association (AHA) to identify patients whose blood pressure measurements place them into one of the established hypertension categories. Identified patients are displayed on an action worklist for review by nurses, care providers, and care coordinators. Those patients can then be referred to a physician for follow up or outreach.

      Undiagnosed Diabetes Surveillance – This diabetes surveillance dashboard was developed to identify patients whose blood glucose readings place them in one of the categories for diabetes based on an automated review of the medical record, but whose disease is currently undiagnosed by a physician. The Diabetes Surveillance Dashboard uses generally accepted guidelines by the American Diabetes Association (ADA) to identify patients whose blood glucose measurements place them into one of the two categories: prediabetic or established undiagnosed diabetes. Identified patients can be displayed on an action worklist for review by nurses, care providers, and care coordinators. Those patients can then be referred to a physician for follow up or outreach.

      Social Determinants of Health (SDoH) – This dashboard visually displays the SDoH factors that influence health outcomes within a given population. These non-medical factors include conditions in which people are born, grow, live, work, and age. These conditions include factors such as socioeconomic status, education, neighborhood, employment, social support networks, access to health care (or lack thereof, and more. This fully interactive dashboard features a live map and enables drill down to dimensions such as location (city, state, ZIP etc.), individual member, age, claims history and amounts, diagnoses and procedures, overall risk, group membership, and more.

      Managing Cases that Require Further Investigation

      Special Cases – This dashboard provides a comprehensive look at high-cost groups that may require more proactive case management and care coordination. Groups such as maternity patients, frail patients, and members with unusual or unexpected cases are profiled and presented for analysis and outreach. The dashboard is subdivided into the following categories (tabs):

      • Frailty Profile – This is a cost and risk profile that identifies and lists frail patients across the population. Frail patients are those patients exhibiting clinical characteristics such as Difficulty in Walking, Unusual Weight Loss, Malnutrition, Absence of Fecal Control, and Fall, among others.
      • Maternity Profile – This is a profile of maternity patients across the population, including active pregnancies and pregnancies that have resulted in deliveries during the service period and those that did not. A live map shows the geographical clusters of each group of maternity cases as well as complete patient listings and comprehensive clinical profiles.
      • Unusual Cases – This tab flags patients with cases that have been identified as being outside of normal or expected ranges. Such cases include members with utilization costs of less than $100 over a year, patients with zero dollars in costs but having active diagnoses, patients with more than 30 outpatient visits or inpatient stays longer than 30 days, and unusual diagnoses for males, females, and pediatric patients.
      • Patient Profile – This is an individual profile page for each patient within the population being analyzed. This profile page is available within all dashboards that show patient listings and represents the final drill down path from any dashboard or report.

      Payment Integrity: Identifying Costly Inefficiencies, Fraud, Waste, and Abuse

      This optional module utilizes a series of sophisticated algorithms to mine medical and pharmacy data to uncover costly, avoidable, and systemic inefficiencies, wasteful spending, potential fraud, abuse, and other unnecessary costs that exist within most health plans, enabling the client to identify and quantify – in precise dollar terms – opportunities for cost reduction and to take concrete actions to minimize those costs and prevent them from reoccurring.

      The Opportunity Discovery module is ideal for plan design and formulary design and is typically deployed for ongoing, enterprise-wide cost containment initiatives.

      The module is subdivided into the following content categories:

      Pharmacy Opportunity Discovery – The drug cost opportunity reports in this content area provide findings in several areas of prescription drug use and prescription patterns. Inefficiencies occur within formularies and within pharmacy spend as a whole and typically fall into various practices such as prescribing costly brand name drugs when lower-cost generic equivalents or lower-cost generic therapeutic alternatives are available, prescribing higher-cost generic drugs instead of equal and clinically effective lower-cost generic drugs, and more.

      The information presented on these pharmacy opportunity reports acts as a summary of findings for pharmacy spending patterns within your formulary and provide a picture into your formulary inefficiency as well as displays precise dollar amounts in savings opportunities that can be achieved by making the necessary formulary design changes.

      The following reports are included in Pharmacy Opportunity Discovery module:

      • Best Buy Generics (BBG) – This report identifies the generic drug that is the best value within a drug category that has multiple generic drug options.
      • Generic Equivalent (GE) – This report identifies when brand name drugs were dispensed and a lower-cost generic equivalent was available.
      • Branded Generics (BG) - This report identifies prescriptions within your formulary where a Branded Generic (BG) was given instead of a therapeutically equivalent, unbranded, less expensive generic.
      • Generic Therapeutic Alternatives (GTA) – This report identifies cases when a single-source brand name drug was dispensed when a lower-cost, generic therapeutic alternative (GTA) was available.

      Medical Opportunity Discovery – Most medical services are best thought of as commodities. There is little to no difference in quality for these services, so there shouldn’t be any justification for significant price variations between the Places of Service (POS) where these services are rendered. Significant price variations between these services is a strong indicator of wasteful spending and inefficiencies within a health plan.

      These POS inefficiencies occur largely due to legacy billing systems and questionable reimbursement practices. They also occur because of intentional efforts by some providers to take advantage of billing loopholes that allow for higher reimbursement for the same service if it is billed as an outpatient facility claim as opposed to a professional physician office claim.

      The reports in this module shine a light on these types of inefficiencies, analyzing medical claims for avoidable, wasteful spending in different service areas.

      The following reports are included in Medical Opportunity Discovery:

      • Payment Accuracy (PA)
      • Clinical Lab Services (CLAB)
      • Durable Medical Equipment (DME)
      • Evaluation and Management Services (E&M)
      • Administered Drugs and Immunizations (ADI)
      • Imaging Cost Report (ICR)
      • High-Cost Providers (HCP)

      Emergency Room Opportunity Discovery – The ER Utilization cost report(s) in this content area provide insights into emergent and non-emergent ER claims compared to total ER claims. Total ER visits are analyzed and opportunities are presented for redirecting patients based on their presenting diagnoses to other, less expensive places of service such as listed below:

      • Urgent care
      • Physician office
      • Telemedicine

      Data points such as total ER spend, total ER visits, and ER spend Inefficiency Ratio are presented. Identified redirection opportunities are also outlined along with precise dollar amounts in potential savings from those opportunities.

      Some of the ER visit types analyzed for savings and redirection opportunities include the following:

      • Avoidable / Potentially Avoidable
        • Telemedicine Possible
        • Non-Telemedicine Possible
      • Non-Avoidable / Non-Potentially Avoidable

      The following report(s) are included in Emergency Room Opportunity Discovery:

      • Emergency Room Utilization

      Executive Summary – The Executive Summary report highlights the most salient findings and insights from both the Medical and Pharmacy Opportunity content areas. These reports focus on inefficient and wasteful spending and provide insights on potential savings opportunities for the health plan and formulary.

      The Executive Summary report is intended as a way for senior leaders and members of the executive suite to quickly become familiar with the current state of the health plan across several disciplines without having to review each individual report.

      The focus areas of the Executive Summary report include the following:

      • Prescription Drugs Savings Opportunities
      • Medical Claims Inefficiencies and Associated Costs
      • Percent % Inefficiency Score and Spending per Member for the health plan
      • Health plan Inefficiency Ratio by month, quarter, and year (with benchmarks)
      • Total Spending and Potential Savings Opportunities for Medical and Pharmacy Claims

      Finding Help

      Resources Area – This is a module within the HealthAnalytIQ application suite for quick reference as well as step-by-step recommendations for intervention based on the level of risk posed by individual members. Included here are handy references to peer-reviewed recommendations for diagnosing and managing chronic conditions as well as concise definitions for each chronic condition and the criteria for identifying patient populations. Guidelines and conceptual models on episodes of care developed by the National Quality Forum (NQF) are presented in graphical format for a number of chronic conditions. The dashboard is subdivided into the following categories (tabs):

      • About HealthAnalytIQ - This is a brief article that provides an overview as well as describes the main features of the HealthAnalytIQ application suite.
      • About the ACG® System – This brief article provides an overview of the Johns Hopkins’ developed ACG System used within the HealthAnalytIQ application.
      • Definitions – Concise definitions of chronic conditions that are typically tracked across a typical population as well as links to peer reviewed articles on each condition.
      • Interventions – Step-by-step recommendations for intervention based on the level of risk posed by individual members along with references to dashboards and content areas that are appropriate in identifying member groups.
      • Episode of Care: General – This interactive page displays concise medical definitions and patient identification criteria for chronic conditions and categories that have been identified by the Centers for Medicare and Medicaid Services (CMS). Also provided are direct, clickable links to peer-reviewed best practice recommendations for diagnosing, treating, and managing those conditions.
      • Episode of Care: General – Outlines a phased approach to Patient Focused Episode of Care management for at-risk populations.
      • Episode of Care: Diabetes – Outlines a phased approach to Patient Focused Episode of Care management for at-risk populations with diabetes. Includes recommendations for treatment plans, pathways, and other issues to be considered during a typical episode.
      • Episode of Care: Cancer – Outlines a phased approach to Patient Focused Episode of Care management for at-risk populations with cancer. Includes recommendations for treatment plans, pathways, and other issues to be considered during a typical episode.
      • Episode of Care: Cardiovascular – Outlines a phased approach to Patient Focused Episode of Care management for at-risk populations with cardiovascular disease. Includes recommendations for treatment plans, pathways, and other issues to be considered during a typical episode.
      • 6-Month Episode Care Model – Outlines a Multiple Chronic Conditions Conceptual Model Case Study for at-risk populations such as diabetes, COPD, or depression. Conceptual model includes sites and providers, types of care, and priority domains of measurement for a typical 6-month episode of care.
      • Safer and Affordable Care Model – Outlines a Multiple Chronic Condition (MCC) Conceptual Model Case Study with Measurement Opportunities for Safer Care and Affordable Care for at-risk populations such as diabetes, COPD, or depression. Conceptual model includes sites and providers, types of care, and priority domains of measurement.
      • MCC Conceptual Model – Outlines a Multiple Chronic Condition (MCC) Conceptual Model with Measurement Opportunities for Safer Care and Affordable Care for at-risk populations such as diabetes, COPD, or depression. Conceptual model includes sites and providers, types of care, and priority domains of measurement for a typical 6-month episode of care.
      • Aims and Priorities – Outlines National Quality Strategy Aims and Priorities across the following domains: Health People / Healthy Communities; Better Care; and Affordable Care.
      • Improving Maternity Care – Outlines Strategies for driving results aimed at improving Maternity Care via the identification of problems and the establishment of appropriate solutions leading to better outcomes.

      Getting Support

      If you require additional support with this document or with using HealthAnalytIQ, send an email to help@healthcostiq.com with your particular issue or call (800) 526-3540 during regular business hours and a client support representative will gladly assist you.

      Feedback and Product Enhancement Requests

      To log a new feature or product enhancement request, or to report an issue or a bug, please go to the HCIQ Help Desk support request form located at https://healthanalytiq.com/pages/contact to fill out your request.

       

      Additional information and extensive documentation, including product training manuals and how-to videos, can also be found in the HCIQ Portal under the Resources dropdown.