Comprehensive report of medical and pharmacy costs with segmentation by services which can be further sorted to represent a specific LOB, market segment and employer data trends.  These can be displayed in monthly, quarterly or annual time periods.

 

 

Target Audience for this Report

Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, and Utilization Management and Sales and Client Relations.

 

Business Impacts of this Report

Informs health plan of trends shifting from inpatient care to outpatient care over time.  This assists in the evaluation of member education, provider education, and network adequacy.  Service line data is important to understand member population and predict future utilization.  Pharmacy cost detail supports assessment of member health and care management tactics.   Service line detail for all services produces informed strategies for rates and premium setting.

 

Detail and Definitions

 

KPI’s:

Medical PMPM – Total Medical PMPM (Inpatient PMPM + Outpatient PMPM + Professional PMPM)

Inpatient PMPM – Total PMPM for all Inpatient Facility costs.

Outpatient PMPM – Total PMPM for all Outpatient Facility costs.

Professional PMPM – Total PMPM for all Professional costs.

Pharmacy PMPM – Total PMPM for all Pharmacy costs.

 

Graphs:

Inpatient PMPM Trend – Inpatient PMPM trend over trend period.

Inpatient PMPM % Change – Inpatient PMPM trend percentage changed from previous trend period.

Outpatient PMPM – Outpatient PMPM trend over trend period.

Outpatient PMPM % Change – Outpatient PMPM trend percentage changed from previous trend period.

Professional PMPM Trend – Professional PMPM trend over trend period.

Professional PMPM % Change – Professional PMPM trend percentage changed from previous trend period.

Pharmacy PMPM Trend – Pharmacy PMPM trend over trend period.

Pharmacy PMPM % Change  - Pharmacy PMPM trend percentage changed from previous trend period.

 

Report Panels:

Inpatient Codes

  • Service Category – Revenue Code category for service. Note: CMS ACO clients will see all “Other” category for all Inpatient Codes due to the data formats sent by CMS.
  • PMPM – PMPM costs of Service Category.

Outpatient Codes

  • Service Category – Revenue Code category for service.
  • PMPM – PMPM costs of Service Category.

Professional Codes

  • Service Category – CPT Code category for service.
  • PMPM – PMPM costs of Service Category.

Pharmacy Drug Class

  • Drug Class – Drug class of NDC Codes.
  • PMPM – PMPM costs of Drug Class.