Managed Care - September 2008 - (Page 21)

plans. Its name means medical artificial intelligence and signifies the type of model used in applications. Empirically, it looks at patient populations to determine which groups had the best outcomes. Then it looks at the treatment protocols to incorporate in its decision-making. It doesn’t use rules, but finds relationships in the data. The features of the software include predicting potential savings and projecting patient motivation for care management, based on gaps in doctors visits, drug compliance, and other data. Client charges are typically per member per year. Risk Navigator Clinical can be used over Internet, but does not yet work with an electronic medical record in the payer application, only in the hospital application. Physicians can log into a Web portal to access their patient list to retrieve predictions and compliance analysis. Organizations can analyze physician utilization. Various independent physician panels provide validation. Adventist Health System in Winter Park, Fla., was formerly a part owner. Verisk-DxCG/Urix (Urix Analytic Platform) DxCG and Urix were independent companies purchased in 2004 and 2006, respectively, by Verisk Analytics, formerly called ISO (Insurance Services Office), a conglomerate of 17 data management, security, and predictive modeling companies for the insurance indus- try. DxCG (stands for Diagnostic Cost Group) is now a division of Urix. The Urix Analytic Platform (UAP) came on the market in 2001. It serves 12 health plans, TPAs, selfinsured employers, and health and welfare trusts, encompassing 20 million covered lives. Its largest client is Health Care Services, with approximately 3 million lives. Most clients are medium to large health plans. UAP is a rule-based system. Among other duties, UAP produces a relative risk score in expected cost/dollars, predicts illness burden and expense, notes probability of hospitalization in the next six months, identifies conditions that drive risk, detects fraud and abuse, and performs CPT/ICD-9 coding checks. Competitors D2Hawkeye and Thomson Medstat license Urix’s RiskSmart predictive modeling component. DxCG’s original predictive modeling application was validated by the Centers for Medicare & Medicaid Services for Medicare advantage plans in 1996. Since then, independent researchers have offered validation. UAP is available over the Web and through EMRs, though clients haven’t showed an interest in buying the EMR part yet. The company is developing an application so physicians can run the software in examination rooms. D2Hawkeye (D2Explorer) D2Hawkeye is a private company that started selling its flagship software product, Explorer, in 2001. It has developed a niche among thirdparty administrators, but also counts several health plans, self-insured employers, benefit consultants, atrisk provider groups, Medicaid programs, and disease management companies among its 140 clients covering 11 million lives. Some of these clients include Healthways, CoreSource, and Aon. The company charges per member per month. Competitors call D2 Explorer a sophisticated, rules-based application because it uses thousands of algorithms and its statistical methods and cost projections were developed in collaboration with researchers at the Massachusetts Institute of Technology and Harvard Medical School. According to D2 data, 5 percent of members typically account for 65 percent of medical costs. The application reveals costs of various interventions for individuals and populations. Mostly it is nurses who use the application to determine gaps in care for medical management and outreach. One such gap would be a diabetic who is not on an ACE inhibitor. Through its own analysis, performed with a group of its clients, D2Hawkeye found it can save clients money by reducing the number of required nurse calls. The application is available by way of the Internet, but it is not yet linked through EMRs. Some parts are being tested in physician offices. — Maureen Glabman Contributing Editor MC: Let’s say I’m running a health plan, and the physician does something that the Archimedes system says shouldn’t be done. Should that health plan refuse to pay for that treatment for the patient? EDDY: My answer will be parallel to the answer that I would give for guidelines in general. The health plan has to decide whether it’s going to allow the physician to override it and whether it will pay for treatment that otherwise is not recommended. In the same way, Archimedes will offer information and physicians can agree or disagree. There can be conflicts, and the health plan will have to decide whether it is going to allow the physician’s judgment to rule. MC: Are people beating a path to your door to use this tool? EDDY: We have been in business a little over two years now, and we already have many very large clients. Almost everyone who has done one project with us has come back to do multiple projects. It’s doing very well. MC: Is Archimedes profitable yet? Are your expenses covered? SEPTEMBER 2008 / MANAGED CARE 21

Table of Contents Feed for the Digital Edition of Managed Care - September 2008

Managed Care - September 2008 Editor’s Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Archimedes Lends Hippocrates a Hand Some Other Predictive Modeling Programs Messing With Medicare Advantage The Trouble With MAC MedPAC’s Suggestions Sound Familiar The Leader in Patient Satisfaction Formulary Files Plan Watch Tomorrow’s Medicine Ad Index Outlook

Managed Care - September 2008

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