Case Studies

Case Studies

  • Cost and Utilization Management

    Example Project: Implement Managed Care Networks

    We were involved in developing and implementing some of the first preferred provider organizations (PPOs) on the west coast for self-insured employers. We contracted with hospitals, physician groups, and solo practice physicians. We worked with third party administrators (TPAs) to administer the PPO network and other cost management programs (e.g., utilization review, large case management, controls for unbundling and upcoding of services). We established fiduciary standards and responsibilities. The initial PPOs were developed in the mid-to-late 1980s. The PPOs provided coverage for about 100,000 self-insured individuals (employees and dependents). Read More…

  • Efficiency and Quality Measurment

    Example Project: Improve Efficiency of Practitioner Network

    We have worked with leading health plans and physician-hospital organizations on improving the efficiency and quality of their practitioner networks. In this capacity, the audit of each practitioner’s medical claims data and charts focused on quality of care and cost-effectiveness of service delivery–two components of care that are inextricably linked because patients are often subject to health risks associated with unnecessary procedures and tests. In each case, a consistent, valid method for measuring practitioner practice patterns variability was employed. Read More…

  • Disease and Population Management

    Example Project: Implement Disease Management Programs

    We were involved in designing and implementing one of the first disease management programs in the country. The client was a multi-state, energy supply company. We worked closely with ERISA (Employee Retirement Income Security Act of 1974) attorneys to ensure appropriate patient confidentiality, patient contact, program implementation, and program quality monitoring. We helped establish fiduciary standards and responsibilities. The initial two disease management programs–diabetes and asthma–were developed in 1992-1993 and implemented in 1993-1994. Read More…