Global Module

The new Affordable Care Act embodies a fundamental change, from volume-based to quality-based reimbursement, with what's being called a "Global Payment" for a complete episode-of-care. Rather than each provider being paid separately, and for each line item charge code they perform, an Accountable Care Organization (ACO) will be paid a lump sum which it will then distribute to everyone involved in that case. The Global Module in SmartCare® was designed to see what you should be getting paid, and enables you to create disease-specific risk pools to track and design the critical models you will need to monitor your progress.

We start at the 20,000-foot level in the Global Module, looking at the aggregate utilization figures for every resource category, with grand totals of total number of treatments and costs. The highlight of this module is its automatic computation of the Global Payment per episode for the dataset, a critical element of the new healthcare reform law. All of the information on the screen shown here usually takes an actuary 10-15 hours to do. Instead, in the Global Module, when you select the study you want to view, it gives you all of this instantly.

One of the strengths of this module is its ability to display up to 4 studies on the screen at the same time, so that for example, you can compare last year’s data to this year’s, and those against a benchmark. What’s shown here is exactly what you will need to know under the new law. It shows the parent dataset, with all episodes-of-care for the entire year in the column on the right, and then 3 specific groups of episodes, blood-related, neoplasms, and diabetics, in the first three columns. You can see what the global payment should be across the bottom for each disease group. Other highlights of the module are:

• The Global Payment and Utilization calculators which let you quickly see the impact of various carve-out or threshold strategies, so necessary for contract negotiations.
• The Risk Pool window which lets you create a new study of episodes based on any combination of selection criteria, such as those in a common disease group, or being seen by a particular medical group or working for a certain employer. This risk pool can be saved and then accessed directly as another study throughout the rest of the system.