Government Health Plans Including Medicaid and Medicare Advantage

With resources diverted to other Medicaid initiatives like Affordable Care Act compliance or testing new payment models, many states struggle modernizing their Medicaid Management Information System (MMIS). Antiquated systems are ill-equipped to identify and manage high-need populations, quantify social determinants of health, or promote efficiency and transparency.

For methodological and data-availability reasons, quality of care is difficult to compare across Medicare Advantage plans, and overpayments are a significant problem since medical records do not always support the beneficiary's diagnosis-based, risk-adjusted rate. Without access to a centralized data repository, it is difficult to detect fraud and abuse. Payers must also address growing concerns about revenues, financial solvency, consumer satisfaction, and competition.

Building Modern Data Warehouses

Government and corporate health care leaders require agile systems that support real-time analysis to monitor quality and cost, disseminate best practices, improve the use of information technology, and support delivery system redesign and improvement. HealthEC’s modular solution and architecture reduces the need for customization, promotes interoperability and facilitates data exchange.

HealthEC is a valuable partner in aggregating data into an enterprise data warehouse. Our data analysis tools can be used to evaluate performance across financial and utilization metrics, assess quality scores, and facilitate care coordination for patients with two or more chronic conditions. By transforming data into actionable reports, HealthEC empowers health plan leaders to make clinical, quality, and business decisions based on data that has been properly attributed, benchmarked, and calculated.

Expediting Data Analysis to Inform Quality Programs

HealthEC’s advanced data analytics tool delivers real-time financial, operational, utilization, and clinical quality reports. The solution supports executives in monitoring Managed Care Organization (MCO) and provider performance, and measures cost, utilization and compliance. Key analytical insights include:

  • Member distribution across plans/MCOs, providers and organizations
  • At-risk member identification and risk level determination
  • Gaps in care identification
  • Utilization metrics across quality programs such as Health Homes, Quality Improvement Project (QIP), Chronic Care Improvement Program (CCIP), etc.
  • Identification of beneficiaries that are eligible for quality programs, such as those with multiple chronic conditions
  • Member behavior prediction
  • Beneficiary engagement

Evaluating Performance Across Providers, Health Plans and Managed Care Organizations (MCOs)

HealthEC’s flexible system allows users to compare providers, organizations, health plans and MCOs across regional, state and national benchmarks.

We support a wide variety of cost/utilization metrics and measures that cover programs such as Healthcare Effectiveness Data and Information Set (HEDIS), Medicare Shared Savings Program (MSSP), Merit-Based Incentive Payment System (MIPS), Health Homes, Prevention Quality Indicators (PQI), National Quality Foundation (NQF), National Committee for Quality Assurance (NCQA), and Accountable Care Organizations (ACOs). The solution supports comparisons at all levels – from health plan to health plan, organization to organization, organization to practice, practice to provider, and provider to members.

Results are displayed on richly populated dashboards that highlight quality metrics and benchmarks at the provider, practice, organizational and health plan level. This translated data enables well-informed discussions with health plans/MCOs and providers. Examples include:

  • Compliance by quality measure with comparison to benchmarks
  • Enrollment, which can also be sorted by health plan
  • Gaps in care identification
  • Visits/encounters including ER visits, admissions, and home health visits – all of which can be analyzed by month and year-over-year
  • Financial data including total spend and cost per type of care (ER visits, ancillary services, tests, etc.)
  • Pharmacy data

Collaborating with Providers to Manage Risk and Quality

Armed with data and HealthEC’s subject matter experts, government health plan leaders are empowered to collaborate with MCOs, organizations and provider networks to develop innovative programs that promote health equity, and drive value and quality. Our experts provide advisory services to help define performance metrics, test new health-improvement programs, and ensure clinical best practices, efficient care coordination, and adherence to cost management principles.

HealthEC empowers government health plan leaders with high quality data to:
  • Evaluate plan and provider performance across clinical, financial and operational metrics
  • Detect fraud and abuse based on beneficiary’s diagnosis and documented care
  • Identify beneficiaries for targeted care programs
  • Generate reports in real-time for quality improvement initiatives and data submission requirements
  • Develop risk management strategies and quality programs based on population demographics

Population Health Management Suite

HealthEC helps organizations improve patient outcomes, optimize quality of life and manage costs through data integration, analytics tools, and workflow support for clinicians, patients and executives

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