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 available through the use of RPNavigator, 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
case 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,
providing 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 to
effectively 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 case mix and severity adjusting element of CRGs, to perform
true apples-to-apples comparison of provider performance. 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. |
