Healthcare payers are constantly seeking ways to improve the
quality of their members' care while containing administrative and
medical costs. Many have found that an effective way to strike this
difficult balance is to shift from reactive to proactive medical
management by identifying and managing members whose care can be
positively impacted. In order to better structure care management
resources to provide for the greatest economic return, payers are
turning to technology that can gather, process and stratify
clinical data.
Alineo Clinical Intelligence is a mechanism by which claims and
care management data can be queried to identify specific
opportunities for intervention and/or improvement for a member's
care. It automates the utilization of clinical information to
proactively delineate and appropriately interact with
high-cost/high-risk members.
Alineo Clinical Intelligence is comprised of three categories
of clinical rules:
- Preventive Health and Wellness: Rules that identify individuals
who have not participated in industry standard-recommended health
and wellness activities.
- Treatment Opportunities (or Gaps in Care): A series of rules
created from evidence-based medicine standards of care that allow
health plans to identify gaps in a patient's care.
- Case Finding Rules: Rules designed to identify members who are
appropriate for certain care management programs, such as case or
disease management programs.
Alineo Clinical Intelligence is formulated from evidence-based
medicine and the standard of care at all times. It offers a high
degree of flexibility and customization to meet health plans'
specific needs for medical policies, regulatory requirements,
medical management processes and workflow. It features User Defined
Variables and Plan-Specific Clinical Intelligence Rules.
Designed for collaboration and compatibility, Alineo Clinical
Intelligence can interface with a variety of analytics tools to
ensure best-of-breed care management capabilities.
With Alineo Clinical Intelligence as part of the identification
and stratification process, payers can apply analytics to identify
a target population based on confirmed conditions. This enables
payers to more efficiently assign care management resources to
patients who will most benefit from them. Alineo Clinical
Intelligence gives care managers access to individual members'
clinical records with which they can identify specific treatment
opportunities and preventive health and wellness options. This
fosters a more efficient use of resources, improvements to care
quality and cost containment measures.
Based on a payer's particular needs, at the conclusion of the
analytics process Alineo Clinical Intelligence will automatically
route patients to the appropriate care manager according to the
patient's combination of medical condition, severity and the care
management program for which they are appropriately selected.