Use Case Description:

Identify opioid population based on the claim & enrollment attributes for risk stratification & prioritize engagement.

User:

Government- Inspector General of Police office Dashboards

Department:

• State Drug Surveillance , Monitoring & Control,
• Disease Management Units
1. Case Management Sub Units
2. Care management Sub Units
3. Disease surveillance, monitoring & control sub units

Pain Statement:

Due to complex nature of the data & manual processing of insights to take a decision, it has become Challenging to identifying & control health influencing factors , These factors in real world have a direct influence on patient’s risk of an opioid incident/addiction

Objective:

To Identify & control factor the puts the member at risk that could help Government in early identification of high risk member and engage member in Preventive Care

Solution Outline:

A weighted average based model that considers all attributes in claim & enrollment based on the payer’s goal , Based on the nature of the goal the model adjusts the weightage to identify and qualifies the population , which are considered for risk stratification & population segregation in subsequent steps

Use Case Description:

Risk Stratify & prioritize segments for Engagement

User:

Payer- Inspector General of Police Office Dashboard

Department:

• State Drug Surveillance , Monitoring & Control,
• Disease Management Units
1. Case Management Sub Units
2. Care management Sub Units
3. Disease surveillance, monitoring & control sub units

Pain Statement:

Each DM Campaigns has its own agenda and specific requirements collating the “at risk “members and prioritizing the members based on the Claim attributes involves time, effort and resources

Objective:

To provide pro active insights to

• Identify members who are at Risk of Event of Interest-( Identify targets based on Campaign goals)
• Provider best course of action which are observed on a Positive outcome observed (Claims+ Health record)
• Prioritize population engagement so that payer’s can focus on preventive care measure on the targeted population

Solution

Evidence based care is a CDC recommended preventive care approach for treating opioid patients

Translating the EBC and its associated care plan into analytics:

• Apply Positive outcome Claim thresholds on targets,
• Model predicts the risk of an Opioid Event of Interest
• Model recommends ideal treatment options & cost that will lead the target into positive health track

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Use Case Description:

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Strengthening Program integrity based on the Rx

User:

Payer- Program Monitoring Staff

Department:

• FWA-IG Units,
• State Drug Surveillance , Monitoring & Control,
• Disease Management Units
1. Case Management Sub Units
2. Care management Sub Units
3. Disease surveillance, monitoring & control sub units

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Pain Statement:

• Most PHM solutions available does not have Rx based Program Integrity analysis which will help in preventive care planning & cost containment planning.
• Limited Insights provided by Claim + clinical analysis at it tend to provider only care and cost insights whereas FWA analysis will provide proactive insights on potential abuse, misuse of Opioid by patient, provider,& pharmacies

Objective:

To strengthen the Target identification & improve the risk stratification results based on the feedback from FWA analysis by subjecting a claim into variety of ways an Opioid handling entities would abuse the system, Insight would help reduce exposure to opioids and prevent abuse .

Solution Outline:

Claim is subjected to various scenarios in which possible FWA could take place, Predictive Model will identify if claim is clean or a potential abuse /fraud of services and dollar. Model check the integrity of service rendered from Member, Prescriber and Pharmacy perspective.

Use Case Description:

This use case aims to screen Members and collect patterns of prescription drug use using a survey. The responses are analyzed to identify non-medical use / problem patterns ranging from mild to severe. Based on the problem patterns, information booklets are sent to the Member.

User:

Medicaid Beneficiary

Department:

State Health Department

Pain Statement:

Detect emerging problems and intervene early before the condition can progress.

Well-supported scientific evidence shows that less severe forms of these conditions often respond to brief physician advice and other types of brief interventions. 

Objective:

To reduce risk factors and bolster protective factors among Members by providing --

1. Relevant literature in the form of booklets

2. Support Program information available in their State

Solution Outline:

1. Include “Prescription Drug Use” Survey for Members who were prescribed opioids x times for pain management in the last <15/30/45/60> days.

2. Send information booklet(s) that can be downloaded/viewed by the Member.