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The RPNavigator solution is focused to turn
valuable raw claims data into actionable information; providing health
plan executives, medical directors and operations directors,
managers and clinicians with the basis for arriving at financial,
underwriting, medical, case and disease management strategies. One
of RPNavigator's core features is a categorical classification
methodology called Clinical Risk Groups(tm) CRGs; an algorithm
developed by 3M Health Information Systems to stratify and severity
adjust a health plan population. Because of its categorical nature,
CRGs enable clients to track disease progression over time, which in
turn facilitates the evaluation, impact and effectiveness of care
management initiatives and actuarial functions. As a care management
tool, CRGs provide rich, clinically understandable information at a
level of detail, that directs care managers to understand the
population, sub-population and individual-member level pathology and
problems
as well as corresponding resource utilization
in a way that is more efficient than reviewing claim line detail.
CareAdvantage has worked with many
leading integrated delivery systems and managed care companies to
develop effective, affordable and timely data-driven strategies to
improve risk management, network management, contract management,
and operations, case, disease and utilization management. These strategies have helped CareAdvantage clients more
effectively manage disease, establish optimal benefit structures and
contract arrangements. Analyses produced by clients have also helped
improve doctor/patient care, identify high-risk groups, outline
preventive measures, evaluate the care provided by physicians and
hospitals, and objectively predict costs and better manage
resources. CareAdvantage achieves this through our RightPath™ Care Management suite of
solutions and services including a second generation, web based
analytic tool set, RightPath Navigator (RPNavigator).
The following table provides an
abridged overview of the key functional uses of our unique data
mining and data analytical tool, RightPath Navigator (RPNavigator).
| Functional Use |
Benefits |
Sales / Marketing |
- Develop group reporting packages
- Custom design care management
programs
- Shape communication / member education efforts
- Profile groups across numerous measures (i.e. HEDIS)
- Highlight quality of network
- Measure the impact of health status on costs
- Define contribution strategies
|
Care Management |
- Formulate targeted intervention strategies and action
plans
- Track disease progression and quality indicators
- Identify appropriate members for CM / DM programs
- Review results of care management (CM) processes
- Measure the impact of care management programs>
- Balance workload of case managers by burden of illness
- Improve internal processes
- Assess program needs
|
Utilization and Quality
Management |
- Identify members with high resource consumption
- Identify unmet disease and case management needs
- Identify those at risk members that have yet to incur
significant costs
- Identify cost management and quality of care
improvements
- Improve internal processes
|
Network Management |
- Establish standards for providers and monitor
performance
- Profile providers by disease burden
- Structure network around quality, cost and efficiency
- Identify outliers of resource use, preventable
admissions and gaps in care
|
Actuarial and Underwriting |
- Forecast resource consumption, risks, and costs
- Identify opportunities in the context of prospective
cost drivers
- Predictive modeling for effective risk adjustment and
rate setting
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