Shel Gulinson Senior Vice President

Over the past several years, premium increases in many markets have provided health plans with enough revenue to operate profitably even if appropriate medical management programs were not in place. This has changed with many health plans, insurance companies and third party risk managers such as IDNs failing. In fact, the leading cause of death among most health plans has been medical expense ratios that represent losses in excess of premium due to a poor understanding of how to design and implement a meaningful medical management program.

This is very different than what most of us learned in the health plan business. UR and QA processes were thought about in terms of unit price and volume. We separate inpatient from outpatient and many of us have not even measured pharmacy until just the last 10 years when it became a big issue. The problem is when you measure just services used at different locations in the delivery system; you never really get a chance to link all the services together around one or two doctors. The total patient care for a certain individual cannot be compared to other individuals with a similar diagnosis without a large population local or regional database that stratifies patients by severity, age, gender and actual resources used. If we could compare all of that, we could actually determine who was the best provider and why.

From these benchmarks of practice norms in a specified geographic area, we could now start looking at trend factors to alter price and benefits to have a fit with the needs of our populations and a link with the best practitioners for the patient with these same diagnoses. This is what Pendulum can do, right now, today.

We use episodes of care and Johns Hopkins advanced Ambulatory Visit Grouper (AVG) to convert all of your claims and utilization data to measure globally defined groupings of services linked to diagnosis. Once  we have this analyzed we can adjust for complexity and severity to start ranking physicians to a performance criteria  that is regional in care guidelines and , if requested , compared to national norms for organizations of similar size and resource availability..

What makes our process unique is not only are our reports legible and sorted into charts and graphs that give medical directors cause for joy in being able to get at the most important aspects of the delivery system that needs change right now, but we actually calculate the estimated savings for taking one action over another.

Whether you’re a Health Plan or an ACO you are truly in need of prioritized savings and that means using limited resources to go after a focused agenda on a regular basis.

This avoids the trap of the “shiny object” that seems to get everyone’s attention but may be a anathema to the big picture of actually getting at the root cause of a Preventable and Avoidable Cost ( PAC ) in the system. 

While most TPAs can gather good information on hospital costs and some ambulatory cots the Pendulum Health capability narrows this data down to focusing on patient level reporting and grouping by illnesses and disease category . We have available best practices for emergency room management embedded in the system and can offer basic training programs for Medical management departments to begin to link the flow of data to works flows and improvement agendas that are measurable, verifiable and therefore reproducible in the findings 

This represents a new approach to medical management and an opportunity to streamline and connect claims department, clinical decision support and provider relations as part of a larger life sciences approach to medical management.