Government Works Inc.

GWI-UA (Utilization Analytics)/ GWI-Profyle (Physician Profiling)

Extensive utilization management and provider practice evaluation service that actuarially compares utilization by professional providers, networks, hospitals and commercial groups. Providers are placed in effective tiers based on economic and quality to form the basis for pay for performance. Physicians view their evaluation on objective information to help them improve their economic and quality performance.

The system features rigorously case mix adjusted economic medical performance and quality of care measures, producing a relative index of comparative performance.

GWI-Profyle performs risk analysis and physician profiling based on stringent and rigorous guidelines developed by Government works, which include age, gender and diagnosis, plus factoring in co morbidities. Additionally, the system measures economic performance both by resource based units (RBUs) and monetarily. The result is standardized reporting that enables plans to compare providers and networks in terms of quality of care and cost to find the most efficient provider or network of providers. This type of reporting results in the ability to create cost effective provider tiers.

Reports are generated on specific treatment costs for any enrolled population – per member, per month by age and sex at these levels:

• Plan • Physician • Clinical diagnosis
• Commercial group • Patient • Hospitals
• Medical group

The Key to Cost Reduction

Within a provider network, the cost variation between physicians who are above and below average on resource utilization is generally 60 percent. This variation makes it next to impossible to assess real health care costs. Cost management can only occur by reducing the magnitude of this variation.

Based on rigorous analysis across the broad spectrum of the data collection points, GWI-Profyle enables payers to place providers in a tiered environment, which reduces the variation of health care costs across the network.

Consistent observations reveal that 65–70 percent of primary care physicians are both cost effective and offer high quality care. Primary care physicians in this tier have half the catastrophic cases of the 30–35 percent of providers who are not cost effective. Additionally, this majority of PCPs care for 70plus percent of all members in any health plan, having been recognized as effective by members. All reports are available in Microsoft® Excel spreadsheets and in optimized files which can be loaded directly into any data warehouse for further analyses.

Broad Spectrum Use for Health Care Payers

GWI-Profyle measures treatment costs, claims, pharmacy, membership and provider data to produce an expert analysis of quality of care and enable payers across the spectrum of the health care organization to utilize the findings.

Financial Managers perform external audits to reconcile client billing and provider reimbursement.
Contracting Managers develop capitation and other reimbursement contracts.
Underwriting and Actuarial Managers develop and refine rating methods and regulatory rate filings.
Marketing Managers – perform employer group utilization and cost reporting.
Provider Network Developers identify and credential prospective network providers, or re-credential existing network providers.
Medical Executives – develop provider compensation programs based on pay for performance.
Medical Directors – use the system as an educational tool for physicians and as a research tool for developing quality assurance protocols.
Physicians – determine self-evaluation to provide objective information about their strengths and weaknesses relative to their network peers.