Category: Case Studies

Disease and Population Management
By devadmin

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.

Experience

  • Developed a patented system that integrates all inpatient, outpatient, ambulatory, and prescription drug claims data into episodes of care by medical condition (Cave et al, Patent Number 5,970,463). The system was designed to accurately and reliability determine patients with chronic medical conditions, patients at high-risk for a future flare-up of their condition, and patients with an undiagnosed medical condition (e.g., diabetes, hypothyroidism, depression, migraine headaches).
  • Worked with health plans and physician-hospital organizations to support disease and patient management programs, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, and Blue Cross/Blue Shield of Missouri.
  • Worked with large self-insured employers to implement catastrophic case management programs and disease management programs–including diabetes, asthma, cancer, and rheumatoid arthritis.
  • Developed patient outcome measures to evaluate the impact of disease management programs. These measures included reduced emergency use, reduced readmission rates, improved short-form 36 health status measures, increased compliance with prescription drug therapies, reduced cholesterol levels, reduced high blood pressure readings, and reduced lost work time.
  • Performed speaking engagements for trade organizations on disease and patient management, and published many articles in peer-reviewed journals and trade journals on the topic.
  • Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology–providing a strong clinical, statistical, and methodological background.
Efficiency and Quality Measurment
By devadmin

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.

On one assignment, we worked with a large health plan and employed a well-published, claims-based episode of care methodology to identify dermatologists, orthopedists, and cardiologists that had a significantly different practice pattern from their immediate peer group. A subsequent chart audit validated the medical claims results. Several practitioners from each specialty type were eventually deselected from the network.

Experience

  • Developed a patented system that integrates all inpatient, outpatient, ambulatory, and prescription drug claims data into episodes of care by medical condition (Cave et al, Patent Number 5,970,463). The system was designed to accurately and reliability measure practitioners’ efficiency and quality of care.
  • Worked with health plans and physician-hospital organizations to evaluate practitioners’ efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.
  • Familiar with the any willing provider laws, freedom of choice laws, and the Health Care Quality Immunity Act.
  • Worked with health plans and physician-hospital organizations on strategies to improve practitioners’ practice patterns through feedback programs, and to deselect practitioners’ from networks.
  • Performed speaking engagements for trade organizations on practitioner efficiency and quality measurement, and published many articles in peer-reviewed journals and trade journals on the topic.
  • Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology–providing a strong clinical, statistical, and methodological background.
Cost and Utilization Management
By devadmin

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).

Experience

  • Worked with large employers to develop, implement, and monitor inpatient utilization review programs, PPOs and other managed care networks (e.g., mental health networks), large case management and disease management programs, and continuous quality improvement programs.
  • Performed speaking engagements for trade organizations, and published articles on cost and utilization management topics.
  • Worked with health plans and physician-hospital organizations to evaluate practitioners’ efficiency and quality of care, including Allina Medica, Humana Health Plans, Harvard Pilgrim Health Plan, UniHealth America, and Blue Cross/Blue Shield.
  • Experienced in the field of group benefits as a practice leader and consultant at two leading employee benefits consulting firms.
  • Reviewed cost and utilization management vendor contracts to ensure appropriate transfer of legal risk from employers to vendors, documentation of processes for monitoring program quality and service delivery, wording of risk-sharing agreements between vendor and employer, and contract termination clauses.
  • Obtained from the University of California, Los Angeles, a Ph.D. in Health Planning and Policy, and a Masters in Public Health in infectious disease epidemiology–providing a strong clinical, statistical, and methodological background.