In the example above, the slope of the paid trend line (orange) is less than the slope of the allowed trend line (blue), reflecting a cost shift to the employees.
As noted below, these descriptions of metrics, programs, activities and contracts are noted to illustrate but a subset of the elements analyzed within each category.
Metrics useful in analyzing plan performance
for medical and prescription drugs.
• Average Hospital Length of Stay
• Number of Admits per 1,000
• Age, Gender, Demographic Analysis
• Emergency Room Visits per 1,000
• Medicine Possession Ratios
• Diagnoses as % of Total Cost
• Count and Dollars of High Cost Claims
• % of Specialty Drug Spend
Programs used in providing the most effective care for medical and prescription drugs.
• Precertification — Covered by Plan
• Preauthorization — Advance Authorization
• Preadmission — Advance Medical Necessity
• Concurrent — Appropriateness During Stay
• Retrospective — Post Stay Review
• Quantity Limits — Specific Rx Quantities
• Step Therapy — Specific Rx Sequencing
• Formularies — Preferred Drug Lists
Activities to manage conditions to improve care
and reduce need for medical services.
• Case Management — Complex & Costly Cases
• Disease Management — Chronic Conditions
• Wellness Analysis — ROI, Outcomes Based
• Value Based — Transparent, Narrow Networks
• Clinical — Evidence Based Guidelines
• Centers of Excellence — Designated Facilities
• Carveouts — PBM, Organ, Behavioral Health
• Concierge Approach — Services Management
Contracts between payors and providers for inpatient, outpatient and professional services.
• Fee For Service — UCR + Fee Schedule
+ Discount from Billed Charges
• Capitation — Per Capita, Fixed Dollar Amount
+ Full Risk — Professional Services
+ Global Risk — Professional and Institutional
• Incentives — Performance Based Funds Pool
• Case Rate — Single Fee, Certain Services
+ Episode Based Case Rates