Production or Standard Reports in a CRG Format

by Commercial, Medicare, Medicaid Line of Business (LOB)

Unless Otherwise Specified, All Analyses are Performed at Each CRG Level of Aggregation

These Reports are Variance Analyses Utilizing Comparative and Normative Statistics[1]

They are CRG-adjusted Rates and Adjusted Averages with Special Focus (Subset) Data[2]

They Will Be Presented as a Compendium of Report Prototypes With Real, Sanitized Data

First Level Analysis and Reporting

Parameter (Baseline)		Description
1.	Membership Correlates	How many continuously enrolled members are attributed to the group or physician practice. This is the denominator of the per member per month reports or the incidence or prevalence rates. It also allows subset comparisons by member age and sex and by health plan type

Parameter (Baseline)		Description
2A.	CRGs by Frequency	Rank-ordered (R-O) the prevalence of Clinical Risk Groups
2B.	Healthy EDC and/or EPC by Prevalence	R-O Healthy Episode Diagnostic/Procedure Cells[3] for the 50 most frequent conditions
2C.	CRGs by Expenditure	R-O per member per month (PMPM) of CRGs
2D.	Healthy EDC and/or EPC by Expenditure	R-O Healthy Episode Diagnostic/Procedure Cells^3 for the 50 most costly conditions

Parameter (Baseline)		Description
3A.	Case Mix Index Calculation - PCP	Average of the Payment Weights Assigned Each Enrollee
3B.	Case Mix Index Calculation by Subgroup and by Total Group	By System of Care, e.g., Integrated Delivery System; By configuration of a group of practitioners, e.g., by enrollees in a primary care group; by Risk Group

Parameter (UR/QI)

Description

4A.

Actual to Predicted Ratios of Cost and Prevalence of CRGs or ACRGs

(External data by LOB must be used as a surrogate for the “Expected” parameter in first generation reports.)

Primary or Specialty Care Report Card with Ratios

For __________________ Med. Group; Period of Observation ___/___ - ___/___

	Group* All Doctors	All Patients Pt. Visit Rate	Cost ($)	Incidence (PMPM[4])	Admit Rate (PMPY[5])	Ave. LOS	Referral Rate (PMPY[6])
Cluster	Frequency Distribution	Ratio	A/E	A/E	A/E	A/E	A/E
ACRG3
ACRG2
ACRG1
CRGs

* Each Physician’s Panel size >500 Continuously enrolled members

Fig. 1: Actual Verses Expected Reporting

4B.

E&M Codes by ACRG3

R-O Evaluation and Management CPT-4 Codes sorted by the highest tier of data aggregation

4C.

Office visits by Patient by CRG or ACRG

E&M codes per ACRG/PCP PMPY; further refined and reported with respect to age tiers and sex

4D.

Referral Patterns by CRG/ACRG, esp. ACRG3

Referral rate per ACRG (for status) per PCP PMPY (using specialty codes and/or place of service to differentiate PCP from specialist visits)

Parameter (UR/QI)		Description
5.	ER Visit Incidence by CRG or ACRG	Analyze by case-mix and by office visit frequency Emergency Room demographics, i.e., sort by age/sex tiers

Hospital Utilization Parameter (UR/QI)		Hospital Care by admit rate and by ALOS by Type of Specialty (e.g., Oxford’s Room Codes) by CRG or ACRG Note: These Reports have excluded, to the extent possible maternity and obvious trauma. Also, where appropriate, Medical is differentiated from Surgical
6A.	Hospital Utilization: Admission Incidence by CRG or ACRG	Hospital admission rate by CRG or ACRG by doctor a) E.G., examine cases with 1 - 2 day stay - determine if the hospitalization could have been avoided (See Ambulatory Sensitive Conditions).
6B.	Hospital Utilization: days/1000 and ALOS by CRG or ACRG	Days per 1,000 members and average hospital length of stay (ALOS) by CRG or ACRG by doctor
6C.	Hospital Utilization Index by CRG or ACRG	A Composite of Hospital admission rates and ALOS by CRG or ACRG by doctor

Second Level Analysis and Action Planning

Parameter (Accessibility)		Description
“Someone Drop the Ball”?
1A.	“Medical Home” Report	PMPY Office visit accessibility as compared with the peer groups’ averages by ACRG
1B.	“Leakage” Analysis Report	Facility and Professional Components of Hospitalizations and Referrals that occur to Non-par (Out of Network [OON]) providers per ACRG per PCP PMPY
1C.	Unmet Needs Indicator Report	Frequent Flyer Report (E.G., > 2 hospitalizations and/or E.R. visits, >5 O.V, > 6 Rx) by CRG or ACRG by doctor
1D.	Readmissions	Inpatient Readmission Study Using the CRG or ACRG Construct to demonstrate the utilization by types of inpatient service[7].

Parameter (High Cost Focus)		Description
2.	Catastrophic patients By Admits / CGR or ACRG	Analyze > $50,000 cases by case-mix and by office visit frequency

Parameter (Effecting Change)		Description
3A.	HEDIS and Secondary Prevention Report Using Targeted CRGs	The essence of NCQA and other regulatory bodies is to identify opportunities and then effect change. CRGs are an ideal tool for that purpose. These would include Preventive Medicine Type Care parameters, e.g., Diabetic Retinal Examinations
3B.	Significant Clinical Instability or Deterioration	Variances with reference to Industry Expectations for Disease Stability (i.e., change in SOI in CRGs that vary by a preset amount, for instance, > 10%, over a period)
3C.	Preventable Condition by CRG/ACRG—QI Focused Study on “Ambulatory Sensitive Conditions”	Correlation analysis to look at the antecedent and/or follow-up care and change in SOI . Example 1: Pristine and complicated asthma ER/Admit with or without a proximate office visit (O.V.) for a respiratory condition or treatment. Example 2: Failure to keep an O.V. after discharge for depression or mental disturbance.

Parameter (Tracking)		Description
4A	MDC, EPC, EDC, PCD, and CRG/ACRG by doctor, reported PMPM (MEEPC)	a. Average Surgical / Medical Admits by MEEPC b. ALOS by Surgical / Medical / Total by MEEPC c. Ave. Total Charges with Surgical / Medical Breakdown by MEEPC
4B.	CRG/ACRG by Subclass, that is by Severity of Illness (SOI) Subclass – all by doctor, reported per year	a. Average Surgical / Medical Admits by MEEPC by SOI Subclass b. ALOS by Surgical / Medical / Total by MEEPC by SOI Subclass a. Ave. Total Charges with Surgical / Medical Breakdown by MEEPC by SOI Subclass
4C.	MEEPC by Specialty/Service	a. Type of service[8]

Third Level Analysis and Action Steps (Advanced Techniques in Treatment Management)

Parameter		Description
1.	Reinsurance Threshold	Large Cases: User can plug in a threshold amount and evaluate the effects of the reinsurance.
2.	Longitudinal Perspective	Comparative study of all care over time, regardless of setting by CRG/ACRG
3.	Case and Disease Management	CRGs or ACRGs becomes the context for case identification and tracking and they become the standard unit of measurement, monitoring and disease management (3m)
4.	Cohort Study: Disease Progression	Progress and opportunities in disease management are revealed by changed in CRG over time in population subsets[9]. Diseases combinations such as depression and other chronic illnesses.
5.	Disease and Case Mgm’t Initiatives	Appropriate for the more advanced [E.G., 6-9], less stable or deteriorating SOI levels[10]
6.	Outcome Assessment	CRGs or ACRGs