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CAI has designed and developed RPNavigator, our secure Internet accessible information portal, to enable health plans to better understand, quantify and improve the future financial risk associated with:
 - Member populations and their corresponding disease burden in the health plan as well as in market segments and in specific accounts
- Utilization, case and disease management strategies
- Provider network management from a quality and cost-effectiveness perspective
- Predictive modeling at the population, product or account level
RPNavigator has four defined solution channels geared to specific users such as plan administrators, actuaries, and medical and care management staff and include the following:
Health Plan Channel
The Health Plan Channel focuses on the information required for health plan executives to make effective business initiative decisions. The information provided focuses on risk adjustment, reimbursement methodology modeling and plan cost management. Information can be explored by overall plan population, product or employer group, showing actual $PMPMs, eligible membership actual and projected $PMPMs and cost drivers.
Care Management Channel
The Care Management Channel focuses on issues related to case, disease, and utilization management. These analyses provide a drill down capability to the individual claim level as well as to the individual's diagnostic and procedure category level of detail. The analyses provided allow care managers to understand a member's primary chronic disease and other co-morbidities in order to design a more effective plan of care. Using RPNavigator's
Care Management Index (CMI) and projected cost driver status enables prioritization and selection of members for cases and disease management programs. These analyses can also provide helpful information for accurately determining caseload and resource assignments.
Product/Group Analysis Channel
The Product/Group Channel focuses on different population comparisons. In this channel, our clients will be able to compare different employer groups' Burden of Illness (BOI) and/or cost drivers to determine which groups are currently driving medical expenditures as well as which groups will have the greatest impact in the future. These analyses will also compare groups across the population by disease to identify the memberships' disease BOI, proving care management with the information required to focus disease and case management initiatives. These analyses will allow our clients to identify and set disease management priorities on an employer group and product specific basis.
Network Management Channel
The Network Management Channel focuses on assisting health plans successfully manage the quality of care and related medical expenditures by risk groups and individual providers. These analyses provide the information needed to develop comprehensive network strategies for reimbursement and contracting that are aligned with our client's goals and objectives. The Network Management Channel can be used by IPAs or those overseeing network performance to target interventions at the risk group or individual physician level. It uses the exquisite case mix and severity adjusting of CRGs to perform true apples-to-apples comparison of provider performance by eliminating differences due to the differences in the patient population. These can easily form the basis for care plan development or provider education. In addition, tiered co-pays for specialists and quality incentives to PCPs can be based on such analyses since both resource use and quality performance can be case and severity adjusted.
Unparalleled Ease of Use, Speed and Functionality
As you saw demonstrated, RPNavigator turns raw claims, encounter, pharmacy, membership and provider data into actionable information, providing health plan executives, actuaries, account managers, medical and operations directors and clinicians with critical insights for developing care management and network management strategies. From a financial, actuarial and marketing perspective, RPNavigator provides the information necessary for isolating unprofitable or problematic market segments, groups and products, and helps to accurately predict both future costs and resource consumption.
Due to the granularity of the output provided by RPNavigator’s underlying foundational algorithm, CRGs, the tool can provide severity-adjusted member categorization by disease and/or co-morbidities. As is true throughout RPNavigator, drilling down from plan level to group to physician and individual member levels is fast and seamless. At the individual level, a wealth of actionable information is instantly available on diagnoses, procedures, claims and pharmacy files.
RPNavigator uses a number of analytical techniques and mechanisms to enhance the CRGs and assist in the selection of appropriate candidates for case and/or disease management interventions. These include:
- The Burden of Illness Index (BOI), which provides a numerical measure of pure disease severity and probable resource consumption. The BOI is derived for each unique Clinical Risk Group (CRG) assignment, which is honed by the individual’s demographic factors (age and sex). All CRG assignments are founded on logical disease or condition groupings, based on the combination and incidence of ICD-9, CPT IV, HCPCS and NDC codes.
- The Care Management Index (CMI), which is based on a combination of parameters that result in a numerical score. The three components of the CMI include the degree of inappropriate discretionary utilization, disease/condition specific complications (including co-morbid conditions) and gaps in care, inclusive of pharmacy.
- The Disease Progression Index (DPI), which traces the rate at which a given member's disease process is progressing or receding.
- What-if analyses on the fly, e.g. identifying members with more than 5 or 10 or 15 ER visits/yr within seconds on the desktop.
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