Today’s economy has for-profit Managed Health Plans struggling to meet shareholder expectations and not-for-profit Managed Health Plans 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., Commercial, 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. Managed Health Plans need constant insight into what causes premium and medical expense increases and then the ability to model scenarios to contain costs while still providing quality plans. Analytical business intelligence is vital to successful healthcare cost and quality management. Without analytics that clearly illuminate problems and opportunities for improvement, Managed Health Plans fly blind in a turbulent environment.

The Clinical Knowledge Manager (CKM) system is PSIMedica’s unique web-based tool for Managed Health Plans 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 Managed Health Plans 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 Members. 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 Health Plan business functions supported by CKM reports are:

A large part of the Health Plan budget is currently 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 Health Plan is precisely the control of the critical information upon which major medical management and pricing decisions are based.