Real World Solutions

CareQuotient™ is leveraged today at numerous healthcare organizations to take control of their data assets, ask a myriad of questions, gain meaningful insights and use the intelligence derived from their data to solve tactical and strategic problems they are faced with transforming their business models as they shift from Volume- to Value- based reimbursement models.

Some of the transformational solutions powered by CareQuotient™ include:

At-Risk Populations

As both providers and payers increase their focus on managing costs of at-risk populations, understanding and stratifying high-risk patient populations is key (e.g. severity of illness, propensity for utilization and potential cost burden). By aggregating clinical data and overlaying it with industry accepted evidence-based clinical protocols – and then integrating claims data to understand utilization and cost across care settings – CareQuotient™ helps healthcare organizations.

  • Identify and stratify at-risk populations with severity of illness burden
  • Identify gaps within care among individual patients/members in these populations
  • Identify Preventable Events – ER visits, Hospital Admissions and Readmissions, High Cost Imaging, Complications, and Unnecessary Services to name a few
  • Identify expected vs actual Utilization and Cost for episodes of care to provide insights into reduction of utilization and cost while improving efficacy of care in alternative settings
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CareQuotient™ is already benefitting customers adopting the ACO and PCMH models. The solution helps our customers confidently adopt and manage Incentive-based reimbursement contracts and Shared-Risk/Savings contracts. Meaningful insights on Quality, Claims, Operational and Financial performance are provided to develop shared savings and shared risk models that yield long-term value.

Prevention & Safety

preventionThe healthcare industry has expanded its focus on preventive care and renewed its focus on reduction of “never-events” (especially regarding denial of reimbursement, in the latter case). Providers (and payers) need proactive intelligence to improve quality and safety of care processes that result in better health outcomes, mitigation in costs of care and reduction in risk of reimbursements.

UUsing pre-built analytics in CareQuotient™ healthcare organizations are able to increase timeliness of rendering preventive care based on industry accepted evidence-based clinical protocols prescribed by various standards development organizations and medical associations such as NCQA, CMS, USPSTF, and NQF.Similarly, pre-built analytics, based on industry accepted evidence-based clinical protocols, is available in CareQuotient™ for healthcare organizations to identify and act on appropriate policies and processes for patient safety in various care settings, especially during transition of care.

Population Health Intelligence

Improvement in quality of care at a population level, but also being able to affect change in health outcomes for every individual in a given population, is essential to improving outcomes and patient experience during and between care delivered at various care settings, while simultaneously reducing cost of care. This in essence is IHI’s Triple Aim philosophy.

Aligned with this philosophy, PluralSoft powers Population Health Intelligence by presenting a single view of longitudinal, patient-centric information in an actionable format so population health managers can spend less time finding data and more time assessing its meaning and deploying resources for improved Population Health. Finding the data encompasses flexibly defining population cohorts of interest, automating the creation of associated care registries, identifying care gaps for individuals in populations- premised on evidence-based care guidelines.

The CareQuotient™ platform is a trusted “data pallet” with enough pre-built intelligence to manage various shades of Population Health. It covers acute, chronic, preventive, behavioral, demographic, utilization,cost, revenue and other information. It provides the required actionable intelligence and tools for intervention that helps practitioners plan and execute a Population Health Management strategy in a feasible, iterative, scalable and sustainable manner. To administer and monitor efficacy of Population Health Management strategies, CareQuotient™ also provides comparative effectiveness benchmarking. CareQuotient™ provides flexible interfaces to push / pull care related information into andfrom EHR/HIS systems, Case/Care Management applications, and Patient Outreach and Communication applications. These attributes help to engage patients and manage care.

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Using CareQuotient™, our customers gain actionable insights that enable practitioners to effectively utilize evidence-based care guidelines, improve health outcomes, recommend behavioral changes that may improve wellness and control chronic illnesses, improve patient experience, demonstrate proof of quality improvement and simultaneous cost reduction, and benefit from evolving value-based reimbursement programs.

Potential Preventable Events

cautionPerformance-based payment reform provides a financial incentive for providers to reduce unnecessary services, thereby lowering costs, improving quality and increasing value of a healthcare dollar invested. Under this agenda, Providers need to reduce denial of reimbursements as well as penalties incurred for potentially preventable events that run the gamut of unnecessary or duplicative services (especially high cost tests/procedures), hospital acquired infections, unnecessary ER visits, hospital admissions and readmissions, to name a few.

CareQuotient™ identifies potentially preventable events, defined as services that are unnecessary for effective care or not expected to be provided if effective care was provided according to evidence based care practices. Such insights help inform clinical operations across the continuum of care in creating efficiencies by avoiding unnecessary services proactively, reducing avoidable costs, minimize reimbursement penalties, improving quality and thereby increasing overall value.

Utilization and Cost Outliers

Utlization and costs are two sides of the same coin. Under- and Over-utilization analysis, more often than not, is highly correlated with costs incurred. Gaining opportunities to optimize utilization will lead to optimization of costs.

utilizationOver-utilization refers to services provided at a higher volume (hence cost) than is appropriate or expected. Under-utilization is generally not on a healthcare organization’s radar and, more often than not, is considered good practice. Just as much as over treatment due to over diagnosis can lead to higher than expected cost (and may become un-reimbursable) under-utilizers of today may become over-utilizers of health care services tomorrow. Under and over utilization of services means an opportunity for the healthcare organization to gain operational efficiencies to meet or exceed its business performance goals – be it quality, cost or revenue.

CareQuotient™ aggregates utilization and cost data (including recommending mechanisms for proxy pricing when costs are not available) across common dimensions such as Provider, Payer, Geography, Race, Gender, Ethnicity, etc. The aggregated data presented at a population level (using pre-established industry accepted measure standards for Quality and Access/Use of Services) can be drilled down to the patient level to identify outliers at a provider, practice, region and overall program.

Our customers maximize CareQuotient™ to monitor service patterns with an aim to ensure that patients receive effective, high quality care, and at the same time, eliminate waste – thereby reducing avoidable costs. The end goal for our customers is to progressively march towards their charter of becoming a High Performance Healthcare System – become and gain recognition for specific Centers of Excellence (enabling them to get preferred contracts), establish and monitor clinical best practices, and operate under a lean agenda.

Performance Reporting

Implementing healthcare reform measures impacts every facet of a healthcare organization’s operations. HIPAA compliant electronic transactions, privacy, confidentiality and security are just the tip of the iceberg. PluralSoft can help your organization achieve sustainable performance improvements to meet your compliance challenges in this complex and transformational regulatory environment – and to meaningfully use secure data to reform.
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For starters, CareQuotient™ is architected to be HIPAA Compliant from a Privacy (consent) and Security perspectives (both Data and Access).For healthcare organizations intent on meeting HITECH Act’s Meaningful Use requirements – for operational use measurement or for clinical quality measurement – CareQuotient™ enables you to demonstrate Meaningful Use to claim the incentives commensurate with its HIT adoption now, and in the very near future, ensure eliminating penalty considerations for not demonstrating expected levels of evolving Meaningful Use – all at a fraction of the incentives received if the healthcare is compliant.

CareQuotient™ is ICD-10 compliant – in that, ICD-10 data intake as well as ICD-10 based quality, cost and revenue life-cycle decision support analyses is built-in. This means future modifications and enhancements are fully addressed in CareQuotient™as the industry evolves its data intake and measurement using ICD-10.

For healthcare organizations contemplating or transforming their business models to value-based reimbursement models, CareQuotient™ provides support for computing nationally vetted and program specific measures. Examples include CMS PQRS measures, CMS ACO measures, CMS TJC measures, Meaningful Use NQF measures, HRSA UDS measures, NCQA HEDIS® measures, USPSTF Recommendations, and many more.

Above all, PluralSoft helps healthcare organizations identify potential risk points regarding HIPAA/HITECH compliance. Assistance is provided with innovation as the organization develops segmentation strategies, centers of service excellence, alternative payment or delivery models, and works collaboratively with other healthcare organizations or payers as partners to optimize their business transformation. PluralSoft partners in your success by: supporting gain sharing and accountable care models, improving sub-optimal systems performance, and alleviating diminished capacity of patient care.

Performance Benchmarking

performanceTo effectively manage what is measured, it is imperative to have capabilities to continuously compare “what” (cost, quality, productivity, efficiency, etc.) is measured for various subjects (Patients, Providers, Care Teams, Care practices or protocols) across various dimensions (Organization wide, Provider Peer groups, Facilities, Payers, Programs such as PCMH or ACO or QI, Contract, Care Modalities, etc.). This is just not just a public relations activity. It is a key tenet of a continuous performance improvement paradigm. It is essential to understand how a healthcare organization can sustain and improve its business in this evolving environment that targets reduction in overall cost of care and simultaneously improving product and service quality while maintaining patient/memberand provider satisfaction.

CareQuotient™ ensures your performance is always monitored over time. Comparison of your organization (and its sub-hierarchy) can be compared against other organizations (and their sub-hierarchies) as well as against available regional / national averages based on a set of metrics of your choosing among hundreds ofpre-built metrics that span quality, utilization, cost and more. Similarly, providers can be compared against providers in the same practice, other higher levels of organization hierarchy or the overall program they participate in. The aggregated data can be drilled down to the patient level to identify outliers at a provider, practice, region and overall program. For quality measures, the benchmarking methodology is based on a set of evidence based guidelines.