Care Management

Clinically-informed insights into member health is a priority for payers. Especially for those members who have a higher prevalence of chronic conditions, disease progression, and emergent conditions. These members need to be identified early in enrollment and prioritized for timely, personalized care-management outreach by the health plan. Furthermore, payers and providers with population health programs are focused on influencing the social determinants of health (SDOH) and need to know where, how, and for whom to invest in the most appropriate, timely and actionable interventions — those that will create the most impact for members and the health plan.

Improve Member Health and Reduce the Cost of Care

Identifying and tracking health condition prevalence, severity and progression among member populations is essential for effective care management and initiatives related to quality management, population health, and SDOH. Our team of experts use clinical and AI-based algorithms built on evidence-based clinical guidelines to identify, stratify, prioritize, and monitor members for payer care-management programs. Additionally, you can utilize clinical lab insights to measure the effectiveness of their care and quality interventions and programs.

Rapidly Improve the following for your Care Management Programs:

  • Disease identification and monitoring
  • Medical cost management
  • Chronic care outreach
  • Rising cost predictions 
  • Disease trend evaluation

Enhance Disease Identification and Monitoring

For improved success with care-management and population-health programs, payers can leverage additional insight from clinical lab-testing data to identify and monitor member conditions earlier and more accurately. Now you can proactively identifying members with worsening conditions and complications versus relying solely on latent and clinically unspecific information found in medical and pharmacy claims. 

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In physician offices, 70% of guidelines are aimed at establishing a diagnosis or managing disease require laboratory tests.

The clinical lab-testing values drive refinement of your algorithms for timely disease identification.

Better Balance Medical Costs with Care Management

Payers understand the importance of balancing overall costs while ensuring members get appropriate and impactful care. Our solutions are designed to measure, track, and respond to medical cost trends. These include:

  • Utilization management
  • Improved cost efficiencies and outcomes 
  • Provider contracting

Optimize Targeted and Timed Chronic Care Outreach

As part of care management programs, members receive personalized educational information, calls from care managers, and online resources. Prognos makes that care management outreach more targeted, accurate and personalized. With clinical lab values,  payers can better:

  • Identify members with the highest opportunity for impact
  • Be more clinically specific and proactive with timely interventions
  • Align the approaches aimed at maximizing member engagement and minimizing provider abrasion

Better Predict Rising Cost with Clinical Data Assets

Clinical lab data is valuable for predicting costs as lab values change across the membership. Research shows that 65% of high-cost members in the current year were not considered to be high-cost patients last year. The ability to identify, predict, and create impactful interventions to target these members is critical for managing medical costs. With powerful and precise insights based on advanced machine learning analytics, Prognos has built powerful models that predict rising costs associated with chronic disease progression and emerging potential clinical issues that require attention.

Payers benefit from our insights for predicting rising costs by more precisely:

  • Planning member interventions 
  • Measuring the effectiveness of population-health programs
  • Investing in programs that have the potential to bend the cost curve

Disease Trend Evaluation

Retrospective evaluation of a population’s disease trends allows health plans to better prioritize members and initiatives, including projects that are aimed at addressing the SDOH. Having deep insight into past trends gives payers a vision for how to manage future programs for members, population management, government programs, and underwriting.