Using the ACG grouper methodology all members are separated into major diagnostic cluster groups, for example, Cardiovascular and then within Cardiovascular into those diseases that are related to this grouping. This report can be used for Care Management in identifying those patients who must proactively be managed to prevent complications of known diseases and or manage patients based on impact and risk.

 

 

 

Target Audience for this Report

Chief Medical Officer, Leadership Team, Medical Management/Care Management Department, and Quality 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

Header

  • EDC Clusters
  • Major EDC Categories

 

Major Expanded Diagnostic Clusters

  • Major EDC Clusters
  • Cases

 

Expanded Diagnostic Clusters

  • Expanded EDC Clusters
  • Patients w/EDC
  • Impact
  • (Impact) Icon

 

% Member by EDC Bands (Multiple Conditions)

  • Number of EDC’s
  • Percentage of Members

 

Providers of Care for Selected Condition

  • Provider
  • Specialty
  • Patients
  • Total Costs
  • Avg Risk
  • Cost/Patient

 

Members

  • Member Number
  • Member Name
  • Gender
  • Age
  • Costs
  • Predicted Costs
  • Admit Risk
  • Coordination
  • # of EDCs