This is a series of six reports that allows the user to evaluate Cost, Utilization, Quality, Pharmacy, Adult Prevention and Child Prevention over time. These visualizations have limited navigation options; platform filters can be applied. 
Panel 1 (top panel)
Shows period level KPI values:
- Trend Level (time period)
- Measure value
- Percent change from last period
Panel 2 (middle graph)
Shows a graphical representation of measure values over time
Panel 3 (bottom graph)
Shows a graphical representation of the percentage of change from the previous period
Major KPI Cost Trends
- Medical PMPM
- Paid/Claim
- Paid/Admit
- Level 4 and 5 E&M (Evaluation and Management) Rate
Target Audience for This Report
Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, and Utilization Management.
Business Impacts of this Report
Medical PMPM cost analysis drives the strategies for UM, authorization processes, actuarial analyses, and network management. Paid/Claim and Paid/Admit identify UM and network opportunities to align members, providers, and costs. E&M Level 4/5 billing tracking and trending offers information on member health and provider care practices. This is a critical element to compare regionally and nationally to ensure providers are aligned with the health plan for quality and effective care.
Major KPI Trends - Utilization
- ER Visits/1000
- Admits/1000
- ALOS (Average Length of Stay in Hospital)
- Lab/Radiology Services/1000
Target Audience for this Report
Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Physician Relations, Quality Management, and Utilization Management.
Business Impacts of this Report
Prior authorization and referral processes within the health plan are informed and decisions regarding requirements for lab, radiology, and ED visits are made based on the trends identified. Concurrent review and discharge planning models can be revised in response to ALOS as indicated by the data. ER visits can be an indicator to examine and improve patient access, can be a measurement of the membership health status, and can be a result of discharge planning outcomes. Provider care trends regarding lab and radiology referrals are critical cost drivers. This data supports physician relations and education for opportunities to reward or revise their current practices
Major KPI Trends - Quality
- Readmission Rate
- Avoidable ER Rate
- Complication Rate
- Hospital Acquired Condition (HAC) Rate
Target Audience for this Report
Chief Medical Officer, Compliance & Regulatory Department, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, and Quality Management.
Business Impacts of this Report
Readmission rates are measured across all LOBs as a critical quality measure and serves as an indicator for pay for performance and gain sharing arrangements with providers. Readmission rates offer an outcome where concurrent review and care management functions of the health plan can be evaluated and improved. Avoidable ER Rate informs the health plan of a key opportunity to reduce costs and improve care continuity by reducing this number. Evaluating patient access to PCPs and Urgent care appointments is important in impacting this rate. Complication rates and hospital acquired complication rates are an important indicator of member's health and the services they receive when hospitalized. The health plan must consider these indicators as an important source of monitoring the providers in their network, the compliance of member's in their care plan, and the ongoing challenge of member communication and support. All metrics in the quality KPI report represent costs which could be reduced or avoided and additional evaluation is warranted.
Major KPI Trends – Pharmacy
- Rx PMPM
- Scripts/Member
- Brand/Generic
- Non-Formulary/Formulary
Target Audience for this Report
Chief Medical Officer, Finance Department and CFO, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, and Quality Management.
Business Impacts of this Report
Evaluation of Pharmacy Benefit Manager (PBM) performance. Monitoring of formulary effectiveness and member/provider education of formulary vs. non-formulary utilization. Utilization patterns of medications, both cost (PMPM) and scripts per member can be evaluated to target care management and medical management strategies. Rx PMPM is a significant cost driver for a health plan and the trending is significant for underwriting, premium and rate setting.
Major KPI Trends – Prevention Adult
- Breast Cancer Screening
- HbA1c
- Eye Exam
- Adult Influenza Vaccination
Target Audience for this Report
Chief Medical Officer, Compliance & Regulatory Department, Medical Management/Care Management Department, Physician Relations, and Quality Management.
Business Processes Impacted by this Report
Identification of gaps in care results in proactive member and provider engagement for outreach and education. Informs quality scorecards and initiatives. Supports provider pay for performance initiatives. Supports the evaluation of the health and compliance of members to determine care management and disease management program development and effectiveness.
Major KPI Trends – Prevention Children
- Children & Adolescent Access to PCPs (CAP)
- Well Child Visits in the First 15 Months of Life (W15)
- Well Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34)
- Adolescent Well Care Visits (AWC)
Target Audience for this Report
Board of Directors, Chief Medical Officer, Compliance & Regulatory Department, Finance Department and CFO, Leadership Team, Medical management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, Quality Management, Utilization Management.
Business Impacts of this Report
Identification of gaps in care results in proactive member and provider engagement for outreach and education. Informs quality scorecards and initiatives. Supports provider pay for performance initiatives. Supports evaluation of the health and compliance of members to determine care management program development and effectiveness. Supports Medicaid reporting requirements.