Today’s economy has Employers and Health Plans struggling
to meet shareholder
expectations and other insurances struggling to maintain
their equilibrium when profits
are squeezed by surging healthcare costs. The task gets even
more difficult when
meeting the demands of multiple regulatory agencies responsible
for oversight of various
products, i.e., Employer-based, Medicare and Medicaid products.
Managing against
employee quality of care expectations has also been a challenge,
especially as the
industry moves towards a more consumer focused selection
of health care vendors.
| TPAs, as the gatekeepers of medical expense processing
and participants in the evaluation and management of
health care services require as much insight into premium
and medical expense increases as all other healthcare
industry delivery system manager. |
The two major businesses of a TPA are fully supported by
the CKM application:
-
Health services
cost management, and
-
Health Service program management,
including consultation.
The
ability to model health delivery and service scenarios, design
interventions to contain
costs while still managing quality plans is achieved
when using the CKM application
Models to guide your analysis. Analytical business
intelligence is vital to successful
healthcare cost and quality management. Without
analytics that clearly illuminate
problems and opportunities for improvement, TPAs
can not promote the successes of
enhanced services in this turbulent health environment.
The Clinical Knowledge Manager (CKM) system is
PSIMedica’s
unique web-based tool
for TPAs which integrates all available cost and
quality information from sources
including medical and hospital claims, pharmacy,
disability, workers compensation,
laboratory and radiology results, dental, vision,
and HRA data on a standardized basis
to support informed health care management. Easy
to use, integrated data enables TPAs
to make decisions about rising benefit costs for
both employer and employees and to
identify strategic financial opportunities or quality
improvement intervention initiatives
that will increase employer satisfaction with its
benefit plans improve the chances of long
term relationships with your employers and other
clients. The crux of successful
management is balancing cost and quality in a productive,
evidence-based manner.
PSIMedica is the premier clinical knowledge management
organization, offering systems
and services that enable its clients to manage
for success.
Among the many business functions supported by
CKM reports are:
-
Actuarially-based health benefit
plan design modeling improving your client’s
response time for State and Federal premium submissions
and increasing the accuracy of benefit plan
design for Employers
-
Health initiatives such as Population
Management, Disease Management,
Preventive Services Surveillance, Workers
Compensation & Disability
Program
management.
-
Financial/utilization profiles by
Employer Group, Benefit Plan, provider, disease,
etc.
-
Client/Employer specific Report Card
-
… And many more
A
large part of the Healthcare budget is devoted to organization
of data to support these
business processes or outsourcing
of the management process to
a Third Party.
By
providing unfettered access
to all the relevant data in
one easily
useable,
web-based
format, CKM makes healthcare
decision processes far more
efficient. The
benefit to the
TPA is the control of the critical
information upon which major
medical management and
pricing decisions are based
and an improved ROI for you
and your
clients
through
improved administrative efficiencies
and medical management interventions
and
programs.
|
