F ocusing clinical interventions on high risk patients is necessary for quality of care and cost management. However, health plans are often challenged by lack of historical information on new members. Waiting on the initial office visit or utilization case is too late to proactively manage prevention and disease management in high risk members. SPH has developed a new solution to help health plans identify these high risk members, who may have no previous health history with the plan.
Our solution can match new members against a database of medical and pharmacy claims, which spans more than 12 years of historical data and 280M active patients. Claims data can be used to derive clinical conditions and calculate the Milliman Advanced Risk Adjuster (MARA) score to predict future utilization. Equipped with this information, health plans can better target sub-populations of new members for in-network care earlier.