PMPM Analyzer

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Product Overview

The PMPM Analyzer application supports a holistic evaluation of the drivers of per member per month payment performance. This claims-based tool gives an in- and out-of-network view of payment trends, and gives users the ability to understand how an ACO’s procedures, providers, members, and specialty areas are contributing to overall PMPM payment performance.
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Features

  • Summary-level statistics highlighting PMPM payment trends over time and against target rates
  • Opportunity: review payment variation by provider, specialty, procedure, and diagnosis to explore potential opportunities for standardization
  • Payments: Analyze the providers, members, specialties, and diagnoses that are the greatest contributors to PMPM performance
  • Providers: Explore variation in payment at the provider level; evaluate payments at the provider-level, considering the member's, diagnoses, procedures and care processes that are contributing to the trend
  • Details (member): Explorer variation in payments at the member level; consider the drivers of payments at the member level

Benefits

Quickly identify top contributors to PMPM performance

  • Claims-based dashboard provides a view across the continuum of care
  • Visualize top contributors to PMPM payment trends at the specialty, provider, and member levels

Conduct detailed analyses of PMPM performance to identify opportunities for improvement

  • Drill into PMPM payment trends within each contract to identify major cost drivers
  • In addition to highlighting the top overall contributors to PMPM performance, the tool supports very detailed and comprehensive analyses to identify a wide range of drivers of PMPM payment trends

Faster time to value

  • Eliminate the burden of manually scrubbing and analyzing claims-based files
  • Ongoing claims-based files refreshed as quickly as 24 hours upon receipt

Measures

Available Measures Include:

  • Total payments by care process, diagnosis, procedure, claim type, specialty, provider, and member
  • Variation in total payments per encounter by care process
  • Variation in total payments at the member level, stratified by the member’s risk score

Data Sources

  • Required: Claims data

PMPM Analyzer: A Deeper View

Background

To succeed under at-risk contracts, ACO executives need to successfully manage costs. They must perform better than a PMPM target in order to realize savings and avoid losses. Where ACO Explorer provides an executive-level dashboard that allows the health care organizations to monitor high-level PMPM payment trends, PMPM Analyzer is designed to support analysts doing comprehensive, deep-dive analyses to understand how to improve PMPM performance.

What types of problems does PMPM Analyzer address?

ACOs gain access to claims data to monitor their ACO performance, but may find it difficult to interpret and analyze it. Specifically, it is critical for ACOs to leverage this claims data to monitor their performance on PMPM payment targets. Absent the ability to monitor PMPM trends and identify opportunities to improve, ACOs will lack the ability to strategically improve their financial performance against contractual targets.

Use Cases

A health system and a payer enter a shared-savings agreement, and want to understand how its providers are performing against per-member-per-month targets. Using ACO Explorer, the executive team can quickly see that for the past three months PMPM payments trended below the target, but that there has been a worrisome rise in spend in the last month. The CFO asks her analyst to explore this trend and identify opportunities for improvement. Using PMPM analyzer, the analyst determines that out-of-network service leakage for cardiology is one of the major drivers of rising costs. In response, leadership starts to consider options for better aligning with these specialists.

Anticipated Improvements

  • Identify the primary drivers of overall PMPM to focus improvement initiatives and drive down cost.
  • Monitor the impact of improvement initiatives on PMPM performance.

Success Measure Examples

Opportunity Identification:

  • Identify potential $ saved from reductions in leakage
  • Identify the opportunity to reduce PMPM payment rates by improving outreach to high-risk, high cost members