Our firm has extensive experience in providing consulting, data analysis and clinical services for utilization review/case management in both Medicaid and commercial fee for service and managed care programs. IHIS Health provides the services of licensed pharmacists and professional staff with extensive experience in clinical and economic evaluations to meet the requirements of the contract. IHIS Health also provides evaluation and assessment regarding the quality of care participants receive as a result of drug therapies based on treatment guidelines and best practices and other clinical intervention and educational support provided for enhancing clinical outcomes.

Utilization Review and Case Management Activities

  • Sample size and study population evaluations
  • Enhanced risk assessment and stratification using predictive cost modeling to determine increased cost of uncoordinated care
  • Uncoordinated care claims analysis using proprietary criteria driven algorithms
  • Statistical comparison methods
  • Age and demographic group selection and measures
  • Disease assignment and classification instruments
  • Health quality assessment tool evaluation and use
  • Outcome and data measures selection
  • Selection of study instruments
  • Study exclusion criteria
  • Study design and cost and quality evaluation methods
  • Intervention design and evaluation

Summary of Analytical Findings and Identified Savings for State Medicaid Programs

 

IHIS Health provides services to clients for identifying opportunities to improve the coordination of care and intervention strategies to achieve cost savings. While IHIS Health can deliver direct studies, medication management, and other programs, IHIS Health can also provide – with key partners as necessary – insights to improve Federal and state program design and health plan design.

  • Identify & reduce unnecessary and fraudulent costs

  • Improve quality of care

  • Medication use management

  • Disease & care management

  • Address disparities

  • Identify and classify patient safety and access issues

  • Solve operational and system problems

  • Measure cost savings and success

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Designing and developing new provider delivery and payment models to engage providers to be active participants in assisting patients with achieving coordinated care through engaging stakeholders, such as hospitals, physician groups, pharmacists, and patient advocates to assume enhanced patient management activities in a multidisciplinary team approach via accountable care organizations, patient centered medical homes and other integrated models of care

care-utilization

Institute for Innovation Healthcare Strategies’ personnel have extensive experience in providing consulting, data analysis and clinical services for utilization review/case management in both Medicaid and commercial fee for service and managed care programs. IHIS Health provides the services of licensed pharmacists and professional staff with extensive experience in clinical and economic evaluations to meet the requirements of the contract. IHIS Health also provides evaluation and assessment regarding the quality of care participants receive as a result of drug therapies based on treatment guidelines and best practices and other clinical intervention and educational support provided for enhancing clinical outcomes.

  • Coordination of Care Program: Opportunities for Savings and Improved Outcomes in Commercial Health Plans and Federal and State Programs
  • Improving Program and Health Plan Design to Reduce Uncoordinated Care, Save Money and Improve Quality
  • Program Cost Containment and Quality of Care Strategies
  • Care and Utilization Management Experience

  • Disease management and health outcome evaluation initiatives
  • Clinical and therapeutic criteria selection and evaluation for utilization review programs
  • Pharmacy and medical service utilization review and intervention protocol design
  • Patient pharmacy compliance monitoring plans
  • Development and implementation of provider and patient  education and intervention programs
  • Design and implementation of medication therapy management programs
  • Educational training programs for disease management, DUR, and compliance monitoring
  • Evaluation and dissemination of practice guidelines and treatment algorithms

IHIS Health provides commercial health plans and federal and state programs support services for identifying opportunities to improve the coordination of care and implement intervention strategies to achieve cost savings:

employer-health-plans-small

  • Identify unnecessary costs

  • Improve quality of care

  • Medication use management

  • Disease and care management

  • Address disparities

  • Identify and classify patient safety issues

  • Identify and classify access problems

  • Measure cost and quality success

IHIS Health Client Services

  • Conducting a baseline health plan claims analysis with periodic updates to identify patterns of uncoordinated care using criteria-driven algorithms that apply a new method for risk stratification based on the highest potential for impactable cost savings and quality improvement (regardless of severity of illness or number of diseases) and characterize specific contributing factors identified.

  • Converting claims level data into patient specific, actionable information profiles that are transmitted directly to the provider(s) at the practice level via secure messaging.

  • Mapping uncoordinated patients to existing care providers for planning and implementation of interventions, care/disease management, and care coordination activities and programs.

  • Evaluation and retooling of existing systems, utilization management and intervention programs to develop and apply common criteria, procedures and systems for enrollment and monitoring of targeted patients with the most cost and quality improvement opportunities.

  • Implementation of new delivery models, pay for performance programs/strategies and expanding existing educational and intervention programs for identified patients to improve care coordination within medical home models, accountable care organizations and other payment and delivery models to promote value driven health care.

  • Integration of existing and new technologies to improve efficiency and patient outcomes, such as electronic health information exchange systems, e-prescribing, secure provider messaging, and other web-based provider monitoring and practice management tools.