Case Study 2:
An Elderplan Program Recoups Hundreds of Thousands of Dollars

A large integrated delivery network in the New York area comprises an array of healthcare facilities and organizations including a hospital, nursing home, outpatient clinics, and ElderPlan, a pilot HMO for seniors designed and developed with Medicare.

The organization brought together 12 analysts and managers from each of the major divisions of the organization to be trained in SmartCare®. After two ½ day sessions, they were able to use all parts of the system. It was particularly useful to be able to see utilization patterns and PMPM resource models for the different divisions side-by-side on the same screen. They are now finding ways to better coordinate care.

One of the organization’s key problems was the ability to clearly define the disease distribution of the elderly component of its population, and more precisely the severity of their diseases since these patients often had multiple chronic conditions. While SmartCare® was proving very useful in tracking episode-of-care costs, the organization was concerned that it was missing out on substantial reimbursements from Medicare. The 3M CRG software was added to the system, and quickly classified every patient into a severity-adjusted disease risk group. Dozens of patients with more serious classifications than anticipated were quickly identified in SmartCare®, along with their entire claims history. The result was the additional reimbursement to this organization of hundreds of thousands of dollars by Medicare.