This report is a breakout by member level, of predictive costs and metrics provided through the ACGs. While this report is normally accessed via a hyperlink from elsewhere in the platform the user can also navigate here directly from the menus, and type a member number into to the “Member” blank, and tab to query a member/patient record.

 

 

Target Audience for this Report 

Finance Department and CFO, and Medical management/Care Management Department.

 

Business Processes Impacted by this Report

This report provides an individual, patient/member level view that is relevant for care and cost management.

 

Detail and Definitions

Navigation on this report is limited, in that it is provided as member/patient level detail for inspection and validation.   Users can navigate to other aspects of the member/patient record via the buttons in the header; “Medical”, “Pharmacy”, “Gaps in Care”, and “Claim Detail”.

 

Header

  • Member Number
  • Member Name
  • Age
  • Gender
  • Observation Period (Last 12 months)
  • PCP Name
  • PCP Group

 

Member’s Cost Metrics

  • Risk Group
  • Total Costs
  • Pharmacy Costs
  • ACG Category

 

Other Utilization Metrics

  • PCP Name
  • Unique Providers
  • Specialty Count
  • Generalist Seen
  • ER Visit (No Admit)
  • Major Procedure
  • Major Provider of Care

 

Care Management Indicators

  • Risk Score
  • Chronic Conditions
  • Cost Band
  • Resource Utilization
  • Rx Gaps
  • Frailty Flag
  • CM Programs
  • Coordination Risk

 

Member Clinical Markers

  • Clinical Marker
  • Marker Indication (See Legend)

 

Member’s Predictive Costs

  • Predictive Costs Category
  • Predictive Costs Value

 

Predictive Hospitalization

  • Predictive Use Category
  • Predictive Use Value

 

Patient ACG Markers (Medical Data)

  • Major EDC
  • Major EDC Description
  • EDC Description
  • Impact Type

 

Patient ACG Markers (Pharmacy Data)

  • Major Group
  • Major Group Description
  • Group
  • Impact Type