GWI-UM
is an extensive utilization management
and provider practice evaluation service
for health care organizations. The system
comprehensively describes all utilization
parameters and actuarially compares
their use by professional providers,
networks of providers, hospitals and
commercial groups. The system features
rigorously case mix adjusted economic
medical performance and quality of care
measures, producing a relative index
of comparative performance.
GWI-UM 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
Manage Risk Based on Business Factors
Analysis includes services rendered to the patient for all services, including inpatient, outpatient, professional and ancillary services. Information from claims, pharmacy, membership and provider is included to produce accurate analysis. Analysis also includes encounter data where a capitation arrangement is present. This enables payers to manage risk based on many business factors and not just the bottom line.
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-UM 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.
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