Phase I consists of two components, the Benefit Plan Evaluation followed by the Care Management Delivery Assessment. This comprehensive opportunities assessment serves as the basis for the next phase, the development of an informed strategy.
Opportunities Assessment
As a result of this assessment process, CAI subject matter experts provide an opportunities analysis that facilitates an employer's understanding of past as well as current benefit plan and care management program delivery and is used to set the appropriate direction for future management programs and purchasing decisions.
This analysis consists of the review of a standard set of employer benefit, carrier and vendor analyses. A number of opportunity areas can be explored with respect to evaluating current program design intent, selection of delivery mechanisms and/or the degree to which both meets the client objectives are met, however this "broad brush" picture provides facilitates an employer's understanding of past as well as future performance, and is used to set the direction for the future programs. Objectives include:
- To examine the structure of benefit plan options and design relative to the employer's population needs
- To evaluate the employer population's utilization patterns on an overall basis and understand their origins
- To assess the efficacy of the employer's approach regarding selection of health plan carriers, Managed Care Organizations and vendors as well as the institution of employer sponsored care management initiatives in the areas of case, disease, disability and network management programs;
- To assess the effectiveness of the manner in which the client has evaluated past performance of health plans, MCO's and vendors in the same areas.
During this assessment, we use existing sources of data from the client and their selected carriers, MCO's and vendors to:
- Review the current range of employer benefit options and their design from an adequacy and appropriateness perspective
- Determine the degree to which selected carrier and/or MCO's offerings coincide with corporate objectives
- Assess past criteria for the selection and retention of health plan, MCO and/or care management entities
- Simultaneously review the scope of each organization's care management program, and a review of the results achieved to date and their likelihood of having an impact on the client's medical loss experience
- Evaluate the chosen carrier, MCO and vendor evaluation methodologies used by the above to prove those impacts
Benefit design and scope
It has been CAI's experience that often benefit offerings are designed in such a way that they provide utilization results that are directly oppositional to the achieving the desired utilization results and medical loss ratios. During this exercise, CAI identifies those benefit options, cost sharing provisions and care management requirements that are likely to be regressive instead of progressive.
Care management program design and scope
During this assessment we review the current scope of the care management programs of the various carriers and MCO's in response to meeting corporate objectives, the medical loss experience and the employer's program delivery intent. This includes a review of the employer's RFP process used to date to select carriers, MCO's and vendors, and the design and focus of the programs. We will also evaluate the adequacy of the staff and allocation of resources at each entity. Clinical support to the programs can also be audited with a focus on workflows and procedures, optimal criteria in place, the staff application of criteria and guidelines, interventional strategies and consistency and physician review support.
Care management systems program result evaluation
A review of the various organizations' care management programs is followed by an evaluation of the results achieved to date. A keen eye is turned to the savings/return on investment calculations used from a number of perspectives such as:
- Utilization rates and bottom line cost, and the degree to which an entity can reliably prove their contribution to that positive impact
- Methods of case mix and severity adjustment underlying those assertions
- Progress made to date from a member objective attainment perspective
- Impact on the client population's disease progression
Provider network and relations
CAI evaluates the current state of health plans', MCO's and/or vendors' relationships with their network or contracted providers relative to their cooperation and participation. In addition, CAI will evaluate specific network management initiatives and their likeliness to have an impact on the medical loss ratio. CAI also reviews provider reimbursement structures and contracts for barriers to effective care management and what an organization's methods are to identify aberrant or outlier providers from a cost and quality perspective. Again, similar to the approach undertaken during the care management assessment phase, the Provider Network initiatives are scrutinized from the same perspectives.
It should be noted that performing such an evaluation using a health plan's, MCO's or vendor's data sources can often have their limitations due to:
- Working with disparate data sources, program designs and populations;
- Controlling for differing care management approaches and workflows;
- Isolating impacts of regional practice and other extraneous differences; and
- Arriving at a credible return on investment conclusions
More advanced and comprehensive evaluation options include:
- To quantify and characterize the employer's disease burden using state of the art categorization schemas
- To assess the past performance of employer health plans, MCO's and vendors and health care initiatives and the degree to which they have been effective in meeting employer objectives, not only from a cost but disease progression inhibition perspective.
- Evaluating health plans, MCO's and vendors side by side in terms of their relative performance
CAI can both utilize a tool that equalizes these disparities and provides reliable ways of evaluating seemingly unlike populations and delivery mechanisms as well as put that tool into the hands of the customer. Please see the section of this services description which discusses, RPNavigator Services for Employers, which discusses how our tool can empower the employer in its pursuit of health care excellence and cost-effectiveness. |
