Can be used to identify high-cost persons prospectively to better forecast their future costs and to proactively identify individuals whose high risk/high cost healthcare needs may be coordinated by care management and targeted outreach.  The integration of past resource consumption for each cost band identifies the members who are most at risk for high costs in the next 12 months.




Target Audience for this Report

Chief Medical Officer, Finance Department and CFO, Leadership Team, Medical Management/Care Management Department, Pharmacy & Therapeutics Committee, Physician Relations, Quality Management, Utilization Management.


Business Processes Impacted by the Report

The leadership/administration of the health plan will use this report to develop strategies that are specific to the characteristics of the member groups.  These include more targeted health management programs that can be shared with external and internal stakeholders.

Finance will gain a clear perspective of the morbidity pattern of populations allowing for the accurate evaluation of the efficiency of population health strategies – such as member outreach, as well as the equitable setting of capitation payments.

Medical Management and Care Management will use this report to identify population subgroups that are especially in need of critical resources and for sorting patients who are likely to require extensive health care resources into targeted programs and interventions.

Value-based reimbursement models where risk is shared can be effectively structured using the analysis provided in this report.

Details and Definitions



  • Projected Costs Bands
  • Members over $25K Projected Costs


Projected Costs Bands

  • Cost Band
  • Patients
  • Avg Risk
  • Prior Cost
  • Prior Cost/Patient
  • Risk Score ACG Future


Resource Utilization

  • Resource Utilization 
  • Patients
  • Avg Risk
  • Prior Costs
  • Prior Cost/Patient



  • Member Number
  • Member Name
  • Age
  • Gender
  • Cost
  • Hospital Risk
  • Predicted Costs
  • Coordination Risk
  • Resource Band
  • (ADG) Clinical Group


Patient EDC (Medical Data)

  • Major EDC
  • EDC
  • MEDC Type
  • Impact Type


Patient Rx MG (Pharmacy Data)

  • Major Rx-MG
  • Rx-Mg
  • Impact Type