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EquityHealth

EquityHealth

EquityHealth

Equityhealth

Question/ Intervention Goal/ Objectives

Using analysis of medical claims and the Methods/Calculations below, EquityHealth works with Employers and their Employees to understand their opportunities to improve Quality and lower the costs of their healthcare services. This is accomplished in an iterative, three step process:

  • Initial Baseline Audit of the Employer’s Healthcare Supply Chain (remittance/claims data) for at least one full year.
  • Based on the Audit results, an Employer-specific Action Plan with interventions that may include any combination of Employee Engagement, revisions to the Transparent Medical Marketplace, Provider Collaboration, Direct Contracting, and Plan/Network design.
  • Iterative cycles of Audit/Plan/Interventions until savings opportunities are exhausted.

Method/ Calculation

The following metrics were reviewed:

Focal Point Valid Metrics: Measure Name & Numerator Valid Metrics: Denominator
Claims payment accuracy/ transparency Dollars paid for claims with one or more errors (e.g. valid member, valid procedure) Total dollars paid by plan
Overspending: High cost episodes of care (> $10,000 for a single episode) Overspend %: (Actual amount paid – Estimated cost of Alternative services)
Overspend per Member: (Actual amount paid – Estimated cost of Alternative Services)
Total spending on High Cost Episodes
# of eligible members (annual)
Overspending: diagnostic services Overspend = (Actual amount paid – Estimated cost of Alternative services)
Overspend per Member = (Actual amount paid – Estimated cost of Alternative Services)
Total spending on Diagnostic Services
# of eligible members (annual)
Overspending: inefficient use of Emergency Department Care (determined by applying American Academy of Urgent Care Medicine guidelines) Frequency of low-value visits: # of ambulatory ED visits with a primary diagnosis included in the urgent care guideline
Potential cost savings Per Member: actual cost of ambulatory ED visits with a primary diagnosis included in the urgent care guideline – estimated cost of Urgent Care visit at clinics accessible to the members
Total # of ambulatory ED visits
# of eligible members (annual)
Hospital Safety % of Admissions at Safe or Recognized Hospitals = # of inpatient hospital admissions occurring at hospitals with a Leapfrog grade of A or B or with a Center of Excellence designation or that has a direct contract with the plan. Total # of inpatient admissions
Surprise Medical Bills – Unplanned Out of Network and Excluded Benefits Total Charges on claims that were denied because the provider was Out Of Network or the service was not a covered benefit # of eligible members (annual)

Findings/ Metric/ Outcome/ Savings

The metrics listed are reasonable and valid methods to gauge the frequency and cost of the events described. The metrics can be used to assess how much opportunity a plan has to improve; the reliability of this estimate varies somewhat with each measure. For example, reducing the percentage of claims that were paid with errors is a simple administrative process and savings will be directly realized. Reducing the frequency of low-value emergency room visits is complex and savings would be more difficult to achieve than the correction of claims payment errors.

Limitations

The extent to which savings are realized depends upon many factors, such as employee communication and incentives to use the alternative medical providers. Thus, the valid and accurate metric is likely to vary from the savings achieved.

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