ActiveHealth Management, Inc. - CareEngine® System

ActiveHealth’s products and services are designed to improve clinical care and outcomes and provide significant return on investment for commercial, Medicare and Medicaid populations.

Situation

According to the 2002 Institute of Medicine Report, between 44,000 – 98,000 hospital deaths occurred in the United States because of medical error. An estimated cost of $17 billion can be linked to medical errors. At the same time, healthcare costs in the United States continue to rise exponentially.

Solution

ActiveHealth Management is a clinically-focused, technology-driven health management and healthcare data analytics company engaged by leading health plans, employers, and government payors to help improve care, prevent medical errors, and reduce medical costs. Over 9 million members nationwide are currently benefiting from programs and services powered by ActiveHealth’s proprietary CareEngine® System. The CareEngine is a patented, analytical technology platform that enables us to continuously compare individual patient information, derived primarily from available administrative claims data, against widely accepted evidence-based best medical practices to provide physicians and members with specific treatment suggestions in situations where the actual care being provided does not meet these standards.

The CareEngine utilizes over 1,000 clinical rules or matrices based on widely accepted, evidence-based clinical standards. These rule sets are developed internally, in consultation with health plan medical directors and panels of medical consultants, and are derived from clinical information contained in national practice guidelines, position statements of major medical societies and well-respected peer-reviewed medical journals. These sources are supplemented with the results from large-scale, randomized controlled clinical trials, as well as medical textbooks and public safety advisories. The rules are designed to identify specific gaps in care, such as misdiagnoses, sub-optimal surgical or medical management, pharmacological issues such as drug–to-drug, drug-to-disease, and drug-to-metabolic interactions, or lack of follow-up or preventive treatment.

The CareEngine continually reviews member data against the evidence-based standards to generate individual patient-level care opportunities, which we call Care Considerations. These Care Considerations are then communicated to the treating physician by fax, mail or phone, depending on the severity of the condition, and can also be communicated directly to the individual member. All Care Considerations are accompanied by references to medical journals or other sources so that the recipient can learn more about the rationale for the treatment suggestion or about the condition generally. Once issued, a member’s treating physician can review the Care Consideration and apply his/her clinical judgment and knowledge of the patient to determine if and how to alter treatment. By combining cutting-edge technology and evidence-based clinical content, the CareEngine empowers doctors, nurses and patients to achieve better healthcare at lower costs

ActiveHealth also provides case management, disease management and utilization management services through its URAC-accredited clinical services division. The Company also provides population-based data analysis services through its Health Data Management Solutions (HDMS) subsidiary.

Better Health and Lower Costs

A randomized, prospective “control group” clinical trial of the utilization and cost savings impact of the CareEngine in a commercial health plan was published in the February 2005 issue of the American Journal of Managed Care. The study examined 35,447 members of a mid-western, university-affiliated managed care plan between the ages of 12 and 64 who had experienced at least one physician claim or pharmacy claim in the 12 months preceding the study.

Out of the intervention group, 46 potentially serious medical errors per 1000 people were identified. This is nearly one for every 20 people. The study also found that, for those members who triggered Care Considerations, the number of hospitalizations in the intervention group was 19% lower than in the control group. Significantly, paid claims overall were $8.07 per member per month (pmpm) lower in the intervention group (after adjustment for trend) than in the control group, indicating an 8-fold return on investment in the first year of intervention. From the perspective of return on investment, the study concluded that for many of the interventions triggered, one would expect ongoing benefits to accrue, suggesting that over time the return on investment may be even greater. This study demonstrated ActiveHealth’s ability to reduce hospitalizations and life-threatening medical errors, and save money.

Conclusion

The use of ActiveHealth’s products and services can improve medical care, save lives and reduce healthcare costs.