Claims-Based Interoperability

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Outcome Evidence

  • In 2016, Partners Healthcare developed the Integrated Care Management Program (iCMP) to identify and risk-stratify patients who could benefit the most from the care management program, resulting in improved patient satisfaction, lower costs, and lower readmission rates. source
  • In 2014, Illinois’ contract with Medicare-Medicaid Plans for its capitated financial alignment demonstration which required plans to stratify enrollees into three levels: low or no-risk; moderate-risk; and high-risk. In 2018, the published results found the Illinois demonstration group had fewer monthly inpatient admissions, emergency room (ER) visits, and skilled nursing facility (SNF) admissions, and a higher probability of any long-stay nursing facility use. source & source
  • In 2017, all dual eligible members in California were required to enroll in Cal MediConnect. California requires all health plans to stratify enrollees into two categories – higher and lower risk. Those deemed higher risk must receive a HRA within a shorter time frame than those with lower risk. This enhanced data sharing has allowed the state to build out stronger provider networks. source & source

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