New Challenges for Providers

Provider organizations are beginning to enter into contracts with insurers that include increasingly large incentives for quality metrics and care coordination.  These contracts also put providers “at risk”, using capitated global payments for the care of populations of patients.  While the exact contract structures are still emerging, it has been estimated that $1 trillion of risk is going to shift from the insurers to the providers through these new structures.  Accountable Care Organizations (ACO), Patient Centered Medical Home, At Risk Contracts, and Bundled Payments are each parts of the larger fundamental trend of shifting risk from the payers to the providers.




With this shift of risk providers are being asked to take on a range of new responsibilities.  Gennius helps providers by creating the tools to manage in this new environment:

Managing to Evidence Based Guidelines

• Overall compliance, MD compliance (YTD, trend)
• Lists of patients that have missed a guideline
• Profile of patient measure compliance for today’s appointments
• Pay for performance projections and intervention priorities

Optimizing Resource Utilization

• Minimizing out-of-network usage (by referring MD, by diagnosis, by institution)
• Minimizing redundant activity (labs, radiology, visits)
• Identification of over-utilization patterns (by population, by MD/practice)

Managing Populations within Global Payment Contracts

• Identification of readmission patients for review
• Identification of high-cost patients (by diagnosis, by MD) for case management intervention
• Identification of high-risk patients for proactive preventative programs.
• Measuring compliance and follow through in preventative programs (Rx compliance, visit activity, vitals monitoring)