Pendulum Health offers an opportunity for employers and members of coalitions to improve their ability to predict care utilization and cost while improving quality of care for their workforce.
How is this done?
Pendulum Health accomplishes this through an in-depth analysis of claims data, benefit, and health services cost information for employees in your specific community. This goes beyond standard claims payment analysis. This analysis uncovers very specific trends for specific hospital, doctor, and pharmacy use so as to get a clear picture of the panel of providers used by your employees.
What makes this unique?
Pendulum Health has access to claims data for insurers and health plans in your region to determine benchmarks of actual performance. By measuring variations and establishing best practices, patterns of practice emerge that identify physicians and hospitals with the best record of quality outcomes and the most reasonable cost.
These care and cost factors are measured on an outcome basis. In other words Pendulum Health can assign a value to a specific network of health services, which enables the purchaser or health plan to predict costs in advance of service.
How is this different from what you're doing now?
Most employee benefit contracts and insurance arrangements have reported units of care and a price of units. The strategy is to cut the volume of services used through preauthorizations and benefit elimination or by increasing employee co-payments. The other strategy has been to reduce the price through discounts and repricing agreements with third parties or fee schedule limitations such as maximum allowable fee schedules.
Pendulum Health learned over the past 40 years of building community health plans and instituting care management principles that when health plans opt for discounts they see a surge in utilization and when they try to limit utilization the price goes up. In addition, when insurers separate inpatient from outpatient services it is impossible to tell which doctors are doing the best job or which hospital has the best services for a certain diagnosis. In short, old-fashioned accounting approaches to medical economics do not work and in fact can actually impede access to quality care.
Pendulum Health has been working with episodes of care and prospective payment issues designed to predict care since the early 1990’s. Pendulum Health’s focus on developing contemporary medical management strategies for both community based health plans and employer purchasers gives Pendulum Health a broad knowledge of reimbursement issues, underwriting options, provider contract negotiations, and general management experience in creating, managing and monitoring multi-specialty panels of providers as well as single specialty arrangements.
Some employers use this information for plan design changes, wellness monitoring, and network evaluation and find it particularly valuable as mergers or consolidations occur and change the workforce utilization pattern.
Pendulum Health represents a team of management executives, clinical specialists, database analysts, biostatistics resource and support staff. All of these individuals have 30 plus years in a variety of settings and are senior leaders in their respective specialties. Their specialties include claims and underwriting operations, credentialing and benchmarking, actuarial science, and employer and physician networking.
Pendulum Health’s clients regularly comment upon the unusual insight and practical recommendations made by its team.
In an era of health reform Pendulum Health sees the self-funding mechanisms change and new opportunities for employers to build their own networks.
Several coalitions have gone as far as to research and design high performance networks that, by virtue of their cots and outcomes, contain physician members with superior quality. These high performance networks are offered alongside the employers’ current network with the understanding that the employer will design and enforce a two or three tier network.
How This Works
This means the high performance network becomes the preferred network with employees being told that using these physicians will mean less out of pocket in terms of copays or deductibles and that coverage will be nearly 10% for services rendered by this inner network. The next tier will be the traditional network that offers 80/20% coverage and copays with maximum benefit limits or large deductibles. The third tier is the out of network physician that employees select. Here there may be limited coverage unless there is a well-documented referral by an in network doctor that has made a determination that by virtue of the disease complexity or lack of availability of select services in the service area this employee must be referred out. If the employee self refers there may be no coverage. The common exception to all of this is a legitimate emergency room visit. Mist plans use the prudent man approach in defining necessity to use the Emergency Department with a large copayment or even denial of coverage should the employee abuse the use of the Emergency room services.
This is adding options and indirectly improving coverage for employees who see the preferred network and Pendulum Health role is to keep score by helping the employer’s current database of claims and utilization data be analyzed going back two to three years, selecting out key physicians whose cost and outcomes are documented and superior, and putting in place a specialized network contract for these select physicians that are part of the elite network of care for employees.
What We Do
Physicians agree to report claims data to Pendulum Health that we then match up and verify against the standards of the contract guidelines agreed to and in this manner Pendulum Health helps:
- Create the High performance network
- Manage the High performance network
- Refine and improve the High performance network