Background
Our client is a large Academic Medical Center located in the Northeast with a direct-to-employer contract managing a commercial employee population. The health system uses Analytics for Risk Contracting (ARC) and the COPE Health Solutions (CHS) Data Analytics as a Service (DaaS) solution to identify specific opportunities and track performance in specific aspects of the benefit design process.
Challenge
The client initially hypothesized opportunities to optimize total cost of care but required evidence driven information to confirm opportunities. Initial hypotheses included: leakage to out-of-network facilities and providers for High Tech Radiology services, such as Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Positron Emission Tomography (PET), and Magnetic Resonance Angiography (MRA) scans.
Approach
Through a combination of client self-service use of ARC and CHS delivery of DaaS, we were able to work together with the client to identify targeted opportunities and specific initiatives to address them. After analysis of data conducted by CHS, one of the opportunities identified was related to clinical continuity (network keepage), with a focus on High Tech Radiology. Understanding and tracking specific patterns in leakage over time helped the client to understand how benefit design could be leveraged to course-correct member behaviors.
By introducing a benefit design component, such that in-network High Tech Radiology Services only cost members a $0 co-pay and out-of-network High Tech Radiology Services cost members a $250 co-pay, our client was able to shift significant utilization from out of network to in network, thus generating additional “keepage” revenue.
Table: In-Network vs. Out-of-Network Percent Utilization across first two years of engagement with COPE Health Solutions
Self-service monitoring through ARC dashboards:
Cost and Use Detail dashboard enables users to select specific service categories, proce-dures (CPT codes/DRGs), network and/or servicing providers.
Outcomes
Our client was able to shift 10% of services from out-of-network to in-network in the first performance year. In the subsequent performance year, an additional 12% of services were shifted in-network, resulting in a total shift of 22%.
Through ARC and our Analytics Service offering, the client continues to monitor shifts to in-network facilities and providers for High Tech Radiology and is exploring further benefit design changes to mimic this same shift for other service categories as well.
To learn more about how we can help you with Clinical Continuity Improvement, contact info@copehealthsolutions.com
or call 213-259-0245.