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cooperative managed care services connections news magazine CMCS Invests In Analytic Software Understanding Yesterday, Working for Today, Changing Tomorrow BY HEATHER HALL, MHA "The Patient Protection and Affordable Care Act has changed the rules of engagement for payers. The health reform environment mandates improved network man- agement, real-time analysis of physician performance and practice patterns, accessible employer reporting, and differentiation of benefit plan offerings. A focus on increasing quality and controlling costs is driving clinical transformation and payment reform." C – Elsevier/MEDai MCS has partnered with healthcare informa- tion technology solutions company MEDai, to implement new data analytic tools. MEDai is part of Elsevier Clinical Decision Support and has an ongoing partnership with Trizetto, the main supplier of CMCS's medical claims software. This partnership combines the claims data here at CMCS with the data analytic tools of MEDai to assist in providing predictive analytics so- lutions for our payer organizations. The solutions gained through the partnership between Trizetto and Elsevier/MEDai will help CMCS and its health plans to improve chronic care management, iden- tify and stratify patient populations, recognize cost drivers for high-risk populations, provide real-time monitoring of member compliance to evidence-based medicine guide- lines, and understand member mo- tivation for self-management. These innovative tools allow for uti- lization of complex data mining tech- nology and access to advanced predic- tive data analytics based on claims and clinical data. This enables health status SCAN ME! To teleport instantly to our website, simply scan this glyph with any QR code reader. monitoring, identification of high- risk members, gaps in care, and op- portunities by which costs can be con- trolled or avoided. By utilizing these analytics, a 360° view (Figure 1) of the patient is possible, enabling the health plan to understand the past, control the present, and change the future. CMCS's utilization of Risk Navi- Figure 1. Source: MEDai.com gator Clinical will allow for easier reporting for all internal and external users, with minimal IT in- tervention. Risk profiles will be cre- ated to forecast member risk, as well as projected cost; ensuring members are placed into the right care man- agement programs. Impact profiles will be used to identify members us- ing four additional impact insights: Acute, Chronic, Motivation, and Movers. These profiles highlight individuals who are in jeopardy of becoming high risk, who are poorly motivated, and/or who currently pos- sess certain acute or chronic health- care conditions. Members with cur- rent low utilization levels and who have the potential to become high- risk within the next year will also be identified for interventions. Aggregate reports are available detailing high-risk individuals by creating a disease registry, care gap profiles, and employer or physician profiles. "Out of the box" reports can also be created to provide in- Connections 2nd quarter 2012 formation to providers and health plans by using the flexible filtering capabilities, as well as the user-de- fined fields CMCS has chosen. With the application of Risk Navigator Clinical, CMCS will be better able to assist health plans in reducing an- nual costs per member, incidence of catastrophic cases, inpatient ad- missions, readmissions, pharmacy costs, and emergency room visits by providing actionable data to the clinical decision makers. Using the analytics of Risk Naviga- tor Performance, providers will have access to enhanced patterns analysis based on admission rates, readmission rates, emergency room visits, as well as outpatient visits and surgical utiliza- tion, physician visits, radiology costs, laboratory costs, and most common National Drug Codes. This will allow effective measurement of provider case mix and efficiency. A full 24 months of episode data will be used for the profiling of providers, networks, and facilities on a progressive timeline to ensure that the data is as current and accurate as possible. With today's ever- increasing focus on quality while controlling costs, advanced data analytics are essen- tial to help CMCS, the providers, and health plans transform patients' health status and enable improved provider performance in prepara- tion for population-based care. CMCS connections 1 2nd qu arter 2012