Email Address: Telephone: (304) 222-0000 State of West ... · State of West Virginia DW/DSS Bureau for Medical Services RFP MED11015 ... Burden: 4.530 Name: Smith, Jane R Disease(s):

State of West Virginia DW/DSS Bureau for Medical Services RFP MED11015

Sample Reports Appendix A

Sample Reports

Appendix A

BCI/DSS Personal Health Record

(PHR)

Member ID: 1191167 Disease Burden: 4.530

Name: Smith, Jane R Disease(s): Diabetes and Asthma

DOB: 04-Oct-1972 CRG S/S: 6-5

Sex: F Cost: $53,305 Projected Cost: $42,382

Admin Claims Providers Pharmacy Diagnoses and Procedures Admits Diagnostic Testing HS History Summary

Address: 1 Flowing Springs Rd Age: 39 Primary Care ID: 207844200

City: Charles Town Gender: F Primary Care Name: Johnson, Robert L.

State: WV Member Months: 12 Address: 12 Washington Rd

Zip code: 25414 City: Charles Town

Telephone: (304) 222-1111 State: WV

Telephone Cell: Zip code: 25414

Email Address: Telephone: (304) 222-0000

Category: MLTN Product: FFS

Policy Type:

Emergency Contact

Name: Telephone Home: Telephone Work:

Telephone Cell: Relationship:

X

WV_DW_DSS-100_3



PHR Administrative Tab

WV_DW_DSS-101_4

IP Cost OP Cost OP Surgery Cost Rx Cost Lab Cost Rad Cost Ther Cost

$25,594 $18,243 $68 $9,469 $554 $474 $40

Date of

ServicePlace of Service Description Units

Primary

Diagnosis

Secondary

Diagnosis

Total

CostNetwork Provider Name

09-Apr-2006 Emergency Room Emergency Dept Visit 1 Migrne Unsp w/o Ntrc Mgrn $23 Y Powell, Ralph


09-Apr-2006 OP Hospital Hydroxyzine Hcl Injection 1 Migrne Unsp w/o Ntrc Mgrn $17 Y Powell, Ralph

09-Apr-2006 OP Hospital Meperidine/Promethazine Inj 1 Migrne Unsp w/o Ntrc Mgrn $6 Y Powell, Ralph

09-Apr-2006 Pharmacy Albuterol 17 $13 Y Johnson, Robert L

09-Apr-2006 Pharmacy Zofran 50 $1,119 Y Johnson, Robert L



03-Apr-2006 OP Hospital Hydroxyzine Hcl Injection 1 Migrne Unsp w/o Ntrc Mgrn $17 Y Powell, Ralph

03-Apr-2006 OP Hospital Meperidine/Promethazine Inj 1 Migrne Unsp w/o Ntrc Mgrn $6 Y Powell, Ralph

01-Apr-2006 Pharmacy Catapres-Tts 3 4 $165 Y Johnson, Robert L

30-Mar-2006 Office Office/OP Visit, Est 1 DM 2 w/o Cmp Nt St Uncntr $23 Y Johnson, Robert L

30-Mar-2006 Pharmacy Hydrocodone-Acetaminophen 25 $9 Y Johnson, Robert L

Admin Claims Providers Pharmacy Diagnoses and Procedures Admits Diagnostic Testing HS History Summary X



DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Claims Detail Tab

WV_DW_DSS-102_4

Provider ID Provider Name PCP Specialty Network Date of Service Place of Service Primary Diagnosis Secondary DiagnosisPrimary

Procedure

Secondary

ProcedureP

710480302 Powell, Ralph J No Y 01-Feb-2006 IP Hospital DM 1 Neuro Nt St Uncntrld Gastroparesis

207844200 Johnson, Robert R Yes Gen Practice Y 01-Feb-2006 IP Hospital Nausea with vomiting DM 1 w/o Cmp Nt St Uncntrld Initial Hospital Care

800566513 Powell, Ralph No Y 01-Feb-2006 Emergency Room Nausea with vomiting Abdominal Pain Epigastric

800566513 Powell, Ralph No Y 01-Feb-2006 Emergency Room Nausea with vomiting Abdominal Pain Epigastric Als1-Emergency

710480302 Powell, Ralph J No Y 02-Feb-2006 IP Hospital Abdominal Pain Oth Spcf St CT Abdomen w Dye

710480302 Powell, Ralph J No Y 02-Feb-2006 IP Hospital Abdominal Pain Oth Spcf St CT Pelvis w Dye

207844200 Johnson, Robert R Yes Gen Practice Y 02-Feb-2006 IP Hospital Nausea with vomiting DM 1 w/o Cmp Nt St Uncntrld Subsequent Hospital Care

207844200 Johnson, Robert R Yes Gen Practice Y 03-Feb-2006 IP Hospital Nausea with vomiting DM 1 w/o Cmp Nt St Uncntrld Subsequent Hospital Care

207844200 Johnson, Robert R Yes Gen Practice Y 16-Feb-2006 Office DM 1 Neuro Uncntrld Gastroparesis Office/OP Visit, Est

207844200 Johnson, Robert R Yes Gen Practice Y 21-Feb-2006 Office Acute Sinusitis Nos Office/OP Visit, Est

010566503 Powell, Ralph No Y 01-Mar-2006 OP Hospital Headache Meperidine/Promethazine Inj

010566503 Powell, Ralph No Y 01-Mar-2006 Emergency Room Headache

010566503 Powell, Ralph No Y 01-Mar-2006 OP Hospital Headache Hydroxyzine Hcl Inj

010566503 Powell, Ralph No Y 01-Mar-2006 Emergency Room Headache Emergency Dept Visit




DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Provider Services Tab

WV_DW_DSS-103_4

NDC Number Description Fill Date Brand Name (Y/N) Quantity Fills Provider Name Cost Pharmacy Name

006033881 Hydrocodone-Acetaminophen 30-May-2006 Y 25 4 Johnson, Robert L $37

575999877 Precision Xtra 30-May-2006 Y 50 18 $1,629

005970033 Catapres-Tts 3 26-May-2006 Y 4 3 Johnson, Robert L $495

575998547 Precision 26-May-2006 Y 8 5 $115

599301560 Albuterol 26-May-2006 N 17 13 Johnson, Robert L $186

000027510 Humalog 26-May-2006 Y 10 10 $789

001730446 Zofran 22-May-2006 Y 50 3 Johnson, Robert L $3,401

003783475 Nifedipine Er 22-May-2006 Y 30 7 Johnson, Robert L $262

370000455 Prilosec Otc 22-May-2006 Y 28 11 Johnson, Robert L $295

501110430 Metoclopramide Hcl 22-May-2006 N 60 14 Johnson, Robert L $178

003782074 Lisinopril 19-May-2006 N 60 8 Johnson, Robert L $125

006035468 Propoxyphene Napsylate w/Apap 19-May-2006 Y 65 18 $309

000930864 Ciprofloxacin Hcl 16-May-2006 N 16 1 $10

007812613 Amoxicillin 15-May-2006 Y 30 6 $59




DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Pharmacy Detail Tab

Disease Category Counts

Cardiovascular System

Hypertension 2

Hypertension NOS/NEC 2

Chest Pain 2

Diagnostic Testing

CT Scan – General 1

Complex Planar Nuclear Medicine 1

CT – Abdominal 1

Mammography 1

Diagnostic Ultrasound Except Vascular 1

Clinical Diagnostic Laboratory Services 21

Glycated Hemoglobin Test 2

Fecal Occult Blood Test 2

Plain Film 7




DOB: 04-Oct-1972 CRG S/S: 6-5


WV_DW_DSS-104_3



PHR Diagnosis and Procedure

Detail Tab

PHR Inpatient Admissions Tab

WV_DW_DSS-105_4

Total Inpatient Cost: $53,305

Admit Date Discharge Date Attending MD Consults Complication-1 Complication-2 Complication-3 LOS Total Cost

28-Jan-2006 03-Feb-2006 Johnson, Robert R 0 6 $12,498

Primary Diagnosis Secondary Diagnosis Primary Procedure Secondary Procedure MS-DRG

DW 2 w/o Cmp Uncntrld Electrolyt/Fluid Dis Nec Initial Hospital Care Subsequent Hospital Care




DOB: 04-Oct-1972 CRG S/S: 6-5


Lab

Test Type Date of Service Result Range

HGB A1c 17-Aug-2006 4.8 14.0-18.0

HBG 17-Aug-2006 L7.0* 42.0-52.0

HTC 17-Aug-2006 L21.1 4.3-6.1

Radiology


Diagnostic Procedures


Key L = Abnormal Low, H = Abnormal High, WNL = Within Normal Limits, * = Critical Value

WV_DW_DSS-106_3




DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Diagnostic Testing Results Tab

WV_DW_DSS-107_4

Analysis Period CRG-SS CRG Description DB Total CostProj Cost

(PMPM)IP Adm Gaps In Care Product

June 2005 to May 2006 6-5 Diabetes and Asthma 4.530 $53,305 $42,382 10 3 FFS

June 2004 to May 2005 6-3 Diabetes and Asthma 3.890 $32,521 $36,859 5 6 FFS




DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Health Status History Tab

Inpatient Parameters AP Value

Admits 4

Days 18

Actual/Expected LOS 0

Outpatient Parameters AP Value

ER Visits 29

OP Hospital Visits 0

Office Visits 12

Lab Tests 53

Radiology 13

Therapy 1

Consults 10

Quality Parameters AP Value

Preventable Admits 0

Gaps In Care 3

Re-admits < 30 days 0

Disease Progression 0

Disease Complication 0

Financial Parameters AP Value

Total Cost $53,305

Inpatient $25,594

Outpatient $18,243

Hospital Outpatient $5,232

Lab $554

Radiology $474

Therapy $40

Office $271

Pharmacy Cost $9,469

Out of Network $0

Pharmacy Parameters AP Value

Total Scripts 62

Brand Scripts 41

Projected/Actual Cost Parameters AP Value

Projected Cost (PMPM) $3,532

Actual Cost (PMPM) $4,442

Projected / Actual Cost Ratio 0.8

Gaps In Care

Asthma Pharmacotherapy

Influenza Vaccine

Pneumonia Vaccine


WV_DW_DSS-108_3



DOB: 04-Oct-1972 CRG S/S: 6-5




PHR Member Experience Summary Tab

Member ID Name

Pro

du

ct

Ag

e

Sex

CR

G S

/S

Dis

ea

se

Bu

rde

n

MM

Co

st

(PM

PY

)

Pro

jec

ted

Co

st

(PM

PY

)

IP-T

ota

l C

os

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(PM

PY

)

OP

-To

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(PM

PY

)

OP

-Su

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os

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(PM

PY

)

OP

-La

b C

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(PM

PY

)

OP

-Ra

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(PM

PY

)

OP

-Th

er

Co

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(PM

PY

)

Rx

Co

st

(PM

PY

)

30494926 Smith, Jane N FFS 15 F 8-4 4.649 10 $405,168 $0 $163,170 $100,983 $0 $3,417 $426 $126 $141,015

62449682 Smith, Jane M FFS 1 F 6-4 3.201 6 $404,099 $29,949 $122,058 $282,041 $0 $75 $0 $0 $0

22184907 Smith, George L FFS 19 M 5-4 5.200 10 $364,781 $123,499 $0 $530 $0 $61 $118 $32 $364,250

62430785 Smith, Jane R FFS 1 F 6-5 3.697 1 $356,486 $34,591 $352,415 $1,910 $0 $25 $842 $0 $2,160

15856365 Smith, George V FFS 24 M 9-4 6.970 9 $356,312 $65,207 $0 $5,992 $0 $0 $2 $0 $350,320

24459233 Smith, George D FFS 18 M 6-3 4.643 12 $329,261 $43,437 $0 $2,484 $0 $61 $41 $57 $326,777

19153618 Smith, George W MCO 1 39 M 6-1 2.253 12 $321,227 $21,081 $0 $3,060 $0 $276 $1,767 $0 $318,167

28837451 Smith, George D MCO 1 46 M 9-5 9.330 9 $272,334 $87,293 $0 $440 $0 $350 $0 $0 $271,894

61662138 Smith, Jane J FFS 3 F 9-6 21.135 8 $253,600 $197,734 $113,616 $119,963 $359 $100 $153 $350 $20,021

03381952 Smith, George E FFS 46 M 9-6 21.135 12 $248,987 $197,734 $244,764 $4,223 $132 $11 $261 $0 $0

62465735 Smith, George A MCO 1 1 M 5-5 1.119 8 $247,292 $10,467 $246,602 $595 $0 $0 $0 $0 $95

45221942 Smith, George P MCO 1 17 M 6-1 3.467 12 $244,367 $32,438 $0 $237,126 $0 $0 $0 $0 $7,241

27789314 Smith, George P FFS 22 M 9-4 10.139 12 $240,332 $94,855 $166,505 $58,347 $0 $797 $1,723 $0 $15,480

02342989 Smith, Jane L FFS 41 F 6-5 4.182 12 $239,519 $39,122 $227,595 $11,246 $0 $1,497 $972 $0 $678

59705883 Smith, Jane MCO 2 19 F 9-4 10.139 5 $238,431 $94,855 $188,360 $48,685 $0 $125 $1,099 $0 $1,386

03864271 Smith, George D MCO 2 29 M 9-2 8.700 12 $232,680 $81,390 $7,032 $213,998 $0 $193 $1,384 $0 $11,650



Population Health Status

Health Status Mem % Mem Avg MM Cost

(PMPM) Cost

(PMPY) Proj Cost (PMPM)

Proj Cost (PMPY)

Avg DB

Total Population 331,318 100 7 $531 $3,966 $682 $8,182 1.124

1 Healthy 185,858 56.10 7 $49 $322 $54 $647 0.173

2 Significant Acute 10,555 3.19 7 $236 $1,723 $196 $2,356 0.316

3 Single Minor Chronic 18,670 5.64 7 $203 $1,479 $216 $2,593 0.499

4 Multiple Minor Chronic 5,088 1.54 8 $341 $2,621 $432 $5,185 0.840

5 Single Significant Chronic 43,679 13.18 8 $518 $4,178 $734 $8,813 1.340

6 - Two Significant Chronic 43,283 13.06 9 $1,277 $12,111 $2,138 $25,662 3.190

7 Multiple Significant Chronic 17,118 5.17 10 $2,024 $19,623 $3,452 $41,424 5.133

8 Complex Malignancies 3,210 0.97 8 $2,178 $17,744 $2,098 $25,174 3.990

9 Catastrophic 3,857 1.16 9 $2,703 $24,808 $4,436 $53,228 6.748

Population Health Status with

Status Detail


(PMPM) Cost


Proj Cost (PMPY)

Avg DB


1 Healthy 185,858 56.10 7 $49 $322 $54 $647 0.173

2 Significant Acute 10,555 3.19 7 $236 $1,723 $196 $2,356 0.316

3 Single Minor Chronic 18,670 5.64 7 $203 $1,479 $216 $2,593 0.499

4 Multiple Minor Chronic 5,088 1.54 8 $341 $2,621 $432 $5,185 0.840

5 Single Significant Chronic 43,679 13.18 8 $518 $4,178 $734 $8,813 1.340

Severity Level 1 29,969 9.05 8 $377 $2,971 $519 $6,224 1.038

Severity Level 2 8,228 2.48 8 $572 $4,767 $882 $10,589 1.479

Severity Level 3 3,619 1.09 9 $985 $8,625 $1,579 $18,947 2.622

Severity Level 4 974 0.29 9 $1,366 $11,861 $1,897 $22,758 2.909

Severity Level 5 491 0.15 8 $1,107 $8,557 $1,410 $16,916 2.539

Severity Level 6 398 0.12 9 $2,082 $18,235 $2,561 $30,733 4.236




(PMPM) Cost


Proj Cost (PMPY)

Avg DB

6 - Two Significant Chronic 43,283 13.06 9 $1,277 $12,111 $2,138 $25,662 3.190

7 Multiple Significant Chronic 17,118 5.17 10 $2,024 $19,623 $3,452 $41,424 5.133

8 Complex Malignancies 3,210 0.97 8 $2,178 $17,744 $2,098 $25,174 3.990

9 Catastrophic 3,857 1.16 9 $2,703 $24,808 $4,436 $53,228 6.748


Drilldown into Status to view

Dominant Diseases


(PMPM) Cost

(PMPY)

Proj Cost

(PMPM)

Proj Cost

(PMPY) Avg DB


6 Two Significant Chronic 43,283 100 9 $1,277 $12,111 $2,138 $25,662 3.190

Severity Level 2 11,514 100 10 $1,263 $12,135 $2,088 $25,056 3.150

Diseases

Schizophrenia and Mod Chronic 2,062 17.91 10 $1,572 $15,282 $2,473 $29,672 3.872

Psych w/o Schiz and Mod Chron 938 8.15 9 $879 $8,147 $1,303 $15,642 1.928

Schizophrenia and Dom Chronic 739 6.42 10 $2,533 $25,362 $3,978 $47,734 5.878

COPD and Other Mod Chronic 553 4.80 10 $673 $6,554 $1,065 $12,777 1.555

COPD and Other Dom Chronic 494 4.29 10 $1,063 $10,440 $1,797 $21,561 2.648

Diabetes and Other Mod Chronic 486 4.22 9 $778 $7,262 $1,263 $15,150 1.913

1 Dom Chron and 1+ Mod Chron 445 3.86 10 $1,410 $14,140 $2,619 $31,424 3.755

Dementia and Dom Chron 439 3.81 10 $2,548 $25,305 $4,017 $48,202 6.097

Diabetes and Oth Dom Chronic 414 3.60 9 $1,113 $9,660 $1,730 $20,756 3.058

Diabetes and Advanced CAD 370 3.21 9 $667 $6,152 $1,593 $19,118 2.473

Schizophrenia and Chronic Level 2 285 2.48 10 $1,153 $10,976 $2,650 $31,802 3.955

Diabetes and Hypertension 265 2.30 10 $508 $5,190 $1,494 $17,927 2.056

COPD and Advanced CAD 259 2.25 10 $729 $7,334 $1,284 $15,406 1.844




Drilldown to Member List Level


(PMPM) Cost


Proj Cost (PMPY)

Avg DB

6 Two Significant Chronic 43,283 100 9 $1,277 $12,111 $2,138 $25,662 3.190

Severity Level 2 11,514 100 10 $1,263 $12,135 $2,088 $25,056 3.150

Disease

Diabetes and Hypertension 265 100 10 $508 $5,190 $1,494 $17,927 2.056

Member ID Name Age Sex MM CRG S/S

DB Cost

(PMPM) Proj Cost (PMPM)

09805774 Smith, George L 44 M 12 6-2 2.047 $115 $1,596

20463858 Smith, Jane 43 F 12 6-2 1.877 $419 $1,463

59251480 Smith, Jane C 56 F 1 6-2 1.879 $5,470 $1,465

16519368 Smith, George 51 M 12 6-2 2.219 $103 $1,730

62506319 Smith, George 78 M 5 6-2 2.207 $47 $1,721

52813112 Smith, Jane M 87 F 7 6-2 2.657 $515 $2,071

47526621 Smith, Jane R 78 F 7 6-2 1.957 $379 $0

26132407 Smith, George A 17 M 2 6-2 1.960 $1,808 $1,528

44711556 Smith, George H 47 M 2 6-2 2.047 $2,458 $1,596

28379164 Smith, Jane 82 F 12 6-2 2.657 $66 $2,071

03030210 Smith, Jane 77 F 12 6-2 1.957 $149 $1,525

59893638 Smith, Jane S 62 F 6 6-2 1.811 $837 $1,412

44868711 Smith, Jane A 67 F 12 6-2 1.811 $1,155 $1,412

18303842 Smith, George R 58 M 12 6-2 2.219 $3,535 $1,730

05352290 Smith, Jane K 42 F 11 6-2 1.877 $449 $1,463

12228567 Smith, Jane G 84 F 11 6-2 2.657 $205 $2,071

06221923 Smith, Jane K 41 F 12 6-2 1.877 $748 $1,463

02360626 Smith, George 49 M 12 6-2 2.047 $383 $1,596



Member Financial Analysis

Member ID Name P

rod

uc

t

Ag

e

Sex

CR

G S

/S

Dis

ease

Bu

rde

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MM

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(PM

PY

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Pro

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(PM

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(PM

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(PM

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OP

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(PM

PY

)

Rx C

os

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(PM

PY

)

30494926 Smith, Jane N FFS 15 F 8-4 4.649 10 $405,168 $0 $163,170 $100,983 $0 $3,417 $426 $126 $141,015

62449682 Smith, Jane M FFS 1 F 6-4 3.201 6 $404,099 $29,949 $122,058 $282,041 $0 $75 $0 $0 $0

22184907 Smith, George

L FFS 19 M 5-4 5.200 10 $364,781 $123,499 $0 $530 $0 $61 $118 $32 $364,250

62430785 Smith, Jane R FFS 1 F 6-5 3.697 1 $356,486 $34,591 $352,415 $1,910 $0 $25 $842 $0 $2,160


V FFS 24 M 9-4 6.970 9 $356,312 $65,207 $0 $5,992 $0 $0 $2 $0 $350,320


D FFS 18 M 6-3 4.643 12 $329,261 $43,437 $0 $2,484 $0 $61 $41 $57 $326,777


W MCO 1 39 M 6-1 2.253 12 $321,227 $21,081 $0 $3,060 $0 $276 $1,767 $0 $318,167


D MCO 1 46 M 9-5 9.330 9 $272,334 $87,293 $0 $440 $0 $350 $0 $0 $271,894

61662138 Smith, Jane J FFS 3 F 9-6 21.135 8 $253,600 $197,734 $113,616 $119,963 $359 $100 $153 $350 $20,021


E FFS 46 M 9-6 21.135 12 $248,987 $197,734 $244,764 $4,223 $132 $11 $261 $0 $0


A MCO 1 1 M 5-5 1.119 8 $247,292 $10,467 $246,602 $595 $0 $0 $0 $0 $95


P MCO 1 17 M 6-1 3.467 12 $244,367 $32,438 $0 $237,126 $0 $0 $0 $0 $7,241


P FFS 22 M 9-4 10.139 12 $240,332 $94,855 $166,505 $58,347 $0 $797 $1,723 $0 $15,480



Member ID Name

Pro

du

ct

Ag

e

Sex

CR

G S

/S

Dis

ease

Bu

rde

n

MM

Co

st

(PM

PY

)

Pro

jecte

d C

ost

(PM

PY

)

IP-T

ota

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(PM

PY

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OP

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(PM

PY

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OP

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(PM

PY

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OP

-Lab

Co

st

(PM

PY

)

OP

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d C

ost

(PM

PY

)

OP

-Th

er

Co

st

(PM

PY

)

Rx C

os

t

(PM

PY

)

02342989 Smith, Jane L FFS 41 F 6-5 4.182 12 $239,519 $39,122 $227,595 $11,246 $0 $1,497 $972 $0 $678

59705883 Smith, Jane MCO 2 19 F 9-4 10.139 5 $238,431 $94,855 $188,360 $48,685 $0 $125 $1,099 $0 $1,386


D MCO 2 29 M 9-2 8.700 12 $232,680 $81,390 $7,032 $213,998 $0 $193 $1,384 $0 $11,650



Member Pharmacy Analysis

Member ID Name Product Age Sex CRG S/S DB MM Rx Cost (PMPY)

Rx Scripts (PMPY)

Generic % Brand Name %

11681427 Smith, George FFS 40 M 6-4 8.476 12 $2,160 439 63.8 36.2

15553911 Smith, Jane M FFS 40 F 9-3 3.872 12 $350,320 435 70.1 29.9

24184062 Smith, Jane M FFS 41 F 7-5 7.472 1 $326,777 427 59.0 41.0

18504028 Smith, Jane L FFS 55 F 7-3 3.938 12 $318,167 425 32.2 67.8

17164427 Smith, Jane A FFS 36 F 9-6 8.694 12 $271,894 423 91.5 8.5

11173482 Smith, Jane A MCO 1 26 F 9-6 7.171 12 $20,021 422 82.5 17.5

06815510 Smith, Jane P FFS 55 F 9-6 8.694 8 $0 421 70.8 29.2

04364543 Smith, Jane FFS 66 F 9-5 7.171 12 $95 415 73.3 26.7

01188780 Smith, George MCO 1 65 M 7-5 5.710 12 $7,241 413 61.0 39.0

13825586 Smith, Jane MCO 1 42 F 6-4 2.175 12 $15,480 409 20.5 79.5

00459231 Smith, Jane S FFS 31 F 8-5 6.125 12 $678 408 58.6 41.4

13983970 Smith, George M FFS 54 M 7-3 4.834 12 $1,386 407 46.7 53.3

21695012 Smith, Jane L MCO 2 47 F 8-4 4.542 9 $11,650 402 51.5 48.5

22276019 Smith, Jane MCO 2 64 F 7-2 4.529 12 $11,178 400 51.0 49.0

07230494 Smith, Jane MCO 2 52 F 9-6 7.171 7 $14,773 400 85.3 14.8

43478967 Smith, Jane FFS 57 F 6-5 2.926 12 $34,919 399 50.6 49.4

Member Service Utilization Analysis

Member ID Name

Pro

du

ct

Ag

e

Sex

CR

G

S/S

DB

MM

Co

st

(PM

PY

)

Pro

j C

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(PM

PY

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IP A

dm

IP D

ay

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ER

Vis

its

Off

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Vis

its

OP

-Lab

Un

its

OP

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d

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its

OP

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er

Un

its

17500663 Smith, George L FFS 62 M 7-4 5.319 12 $41,056 $49,765 7 36 9 4 25 5 14

14206214 Smith, Jane FFS 55 F 8-5 6.793 3 $62,781 $0 18 58 9 3 92 21 0

21579620 Smith, George L FFS 48 M 7-5 5.559 12 $64,952 $52,006 8 20 67 1 180 49 1

16000599 Smith, George C FFS 68 M 9-6 8.694 12 $20,193 $81,342 9 29 4 2 0 3 0

04882818 Smith, Jane J FFS 48 F 9-4 7.016 12 $160,815 $65,641 10 76 7 0 113 16 0

12844850 Smith, Jane MCO 2 63 F 7-4 5.281 12 $15,467 $49,406 6 11 11 3 0 1 0

24004517 Smith, Jane FFS 47 F 7-4 6.016 12 $23,892 $56,282 5 16 5 0 33 5 0

03936377 Smith, Jane R MCO 2 68 F 7-3 4.523 9 $15,547 $42,314 5 6 4 15 0 4 0

61733632 Smith, Jane S MCO 1 4 F 5-1 0.110 12 $750 $0 6 12 6 0 15 1 15



Member ID Name

Pro

du

ct

Ag

e

Sex

CR

G

S/S

DB

MM

Co

st

(PM

PY

)

Pro

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(PM

PY

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IP A

dm

IP D

ay

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ER

Vis

its

Off

ice

Vis

its

OP

-Lab

Un

its

OP

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Un

its

OP

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Un

its

16330566 Smith, George T FFS 64 M 7-5 6.732 12 $25,824 $62,981 6 18 8 0 79 6 3

32006563 Smith, George MCO 1 79 M 9-6 21.135 12 $13,705 $197,734 9 72 15 0 0 0 0

62457113 Smith, George W MCO 1 65 M 7-4 6.411 9 $208,775 $59,982 5 199 1 0 0 0 0

13697141 Smith, Jane FFS 61 F 7-5 5.780 12 $64,603 $54,079 6 37 16 5 50 23 9

49198618 Smith, George W MCO 2 47 M 7-3 6.250 9 $106,335 $58,474 15 51 23 0 112 44 0

10070720 Smith, George FFS 62 M 7-5 6.732 12 $6,326 $62,981 7 40 4 0 0 3 0

56277059 Smith, Jane S MCO 2 60 F 7-6 6.296 12 $35,568 $58,901 10 42 6 0 67 12 1

Member Quality Analysis

Member ID Name Product Age Sex CRG S/S

DB Δ DB MM Cost

(PMPY) Proj Cost (PMPY)

Gaps in

Care

Prev Admits

Re Admits

17500663 Smith, George L FFS 62 M 7-4 5.319 0.000 12 $41,056 $49,765 5 6 4

14206214 Smith, Jane FFS 55 F 8-5 6.793 1.272 3 $62,781 $0 2 6 15

21579620 Smith, George L FFS 48 M 7-5 5.559 0.000 12 $64,952 $52,006 7 4 3

16000599 Smith, George C FFS 68 M 9-6 8.694 0.000 12 $20,193 $81,342 8 1 7

04882818 Smith, Jane J FFS 48 F 9-4 7.016 3.549 12 $160,815 $65,641 11 4 7

12844850 Smith, Jane MCO 2 63 F 7-4 5.281 0.000 12 $15,467 $49,406 4 2 2

24004517 Smith, Jane FFS 47 F 7-4 6.016 0.000 12 $23,892 $56,282 7 2 2

03936377 Smith, Jane R MCO 2 68 F 7-3 4.523 2.658 9 $15,547 $42,314 6 2 1

61733632 Smith, Jane S MCO 1 4 F 5-1 0.11 0.000 12 $750 $0 8 0 3

16330566 Smith, George T FFS 64 M 7-5 6.732 0.000 12 $25,824 $62,981 8 3 2

32006563 Smith, George MCO 1 79 M 9-6 21.135 0.000 12 $13,705 $197,734 4 3 5

62457113 Smith, George W MCO 1 65 M 7-4 6.411 0.000 9 $208,775 $59,982 8 2 4

13697141 Smith, Jane FFS 61 F 7-5 5.78 2.498 12 $64,603 $54,079 8 2 3

49198618 Smith, George W MCO 2 47 M 7-3 6.25 0.000 9 $106,335 $58,474 3 8 12

10070720 Smith, George FFS 62 M 7-5 6.732 0.000 12 $6,326 $62,981 7 3 4

56277059 Smith, Jane S MCO 2 60 F 7-6 6.296 0.000 12 $35,568 $58,901 8 4 8



Provider Quality Analysis with

Benchmark to Aggregate

Total Providers Mem Avg DB

P/A Cost Ratio

Gaps in Care

(PMPY)

Prev Admits

(P1kMPY)

Re-Admits

(P1kMPY)

106 203 0.733 100.1 0.0 0.0 0.2

Provider ID Provider Name Mem Avg DB P/A

Cost Ratio

Gaps in Care

(PMPY)

Prev Admits

(P1kMPY)

Re-Admits

(P1kMPY)

142446 Johnson, Robert D 1 0.186 0.0 0.0 0.0 0.0

143303 Hancock, Joan K 7 0.298 7.0 1.4 0.0 0.0

146668 Johnson, Robert L 1 0.077 0.0 6.0 0.0 0.0

150251 Hancock, Joan P 1 1.602 3.6 4.0 0.0 0.0

153545 Hancock, Joan J 4 1.13 0.6 0.3 0.0 0.0

151397 Hancock, Joan L 1 3.586 1.5 1.0 0.0 0.0

153519 Hancock, Joan R 5 0.111 0.7 1.2 0.0 0.0

146844 Harris, Rosemary A 6 0.536 3.0 0.2 0.0 0.0

140333 Hancock, Joan R 1 0.236 0.0 0.0 0.0 0.0

152220 Johnson, Robert C 7 0.105 5.9 0.0 0.0 142.9

145671 Hancock, Joan L 9 0.464 730.9 0.1 0.0 0.0

143792 Johnson, Robert P 3 1.977 40.8 0.7 0.0 0.0

146910 Harris, Rosemary S 3 0.801 1.4 0.3 0.0 666.7

150310 Johnson, Robert H 1 0.841 2.9 0.0 0.0 0.0

146318 Johnson, Robert J 1 1.603 4.3 1.0 0.0 0.0

146603 Hancock, Joan L 6 0.536 15.9 0.0 0.0 0.0

146378 Johnson, Robert M 1 0.92 9.6 0.0 0.0 0.0

151482 Johnson, Robert M 1 0.236 0.0 0.0 0.0 0.0

153599 Hancock, Joan T 2 0.38 0.0 0.0 0.0 0.0

141432 Johnson, Robert A 1 2.386 2.6 0.0 0.0 5000.0

141808 Johnson, Robert R 1 0.106 0.0 0.0 0.0 1000.0



Provider Financial Analysis with


Total Providers Panel Avg DB

Total Cost

(PMPY)

IP Cost (PMPY)

OP - Total Cost

(PMPY)

OP - RX

Cost (PMPY)

OP - Lab Cost

(PMPY)

OP - Rad Cost

(PMPY)

OP - Ther Cost

(PMPY)

106 203 0.733 $2,314 $0 $1,761 $553 $22 $93 $45

Provider ID Provider Name Panel Avg DB Total Cost

(PMPY)

IP Cost (PMPY)

OP - Total Cost

(PMPY)

OP - RX

Cost (PMPY)

OP - Lab Cost

(PMPY)

OP - Rad Cost

(PMPY)

OP - Ther Cost

(PMPY)

142446 Johnson, Robert D 1 0.186 $209 $0 $0 $209 $0 $0 $0

143303 Hancock, Joan K 7 0.298 $172 $0 $154 $17 $4 $36 $6

146668 Johnson, Robert L 1 0.077 $0 $0 $0 $0 $0 $0 $0

146844 Harris, Rosemary A 6 0.536 $17,320 $0 $16,612 $708 $20 $0 $381

150251 Hancock, Joan P 1 1.602 $4,127 $0 $158 $3,969 $0 $130 $0

151397 Hancock, Joan L 1 3.586 $22,571 $0 $17,522 $5,049 $67 $1,244 $191

153519 Hancock, Joan R 5 0.111 $662 $0 $620 $42 $10 $495 $0

153545 Hancock, Joan J 4 1.13 $14,767 $0 $14,569 $198 $113 $1,392 $0

140333 Hancock, Joan R 1 0.236 $99 $0 $99 $0 $74 $0 $0

143792 Johnson, Robert P 3 1.977 $2,991 $0 $1,473 $1,519 $0 $118 $0

145671 Hancock, Joan L 9 0.464 $2,009 $0 $1,319 $690 $18 $119 $67

146318 Johnson, Robert J 1 1.603 $3,523 $0 $597 $2,927 $30 $114 $0

146378 Johnson, Robert M 1 0.92 $898 $0 $285 $614 $0 $0 $0

146603 Hancock, Joan L 6 0.536 $436 $0 $417 $19 $7 $208 $0

146910 Harris, Rosemary S 3 0.801 $5,102 $0 $4,979 $123 $133 $82 $0

150310 Johnson, Robert H 1 0.841 $2,745 $0 $1,854 $891 $54 $846 $0

152220 Johnson, Robert C 7 0.105 $31 $0 $31 $0 $10 $0 $0

141432 Johnson, Robert A 1 2.386 $8,508 $0 $6,776 $1,732 $39 $0 $0

141808 Johnson, Robert R 1 0.106 $0 $0 $0 $0 $0 $0 $0

142647 Hancock, Joan H 5 0.276 $1,656 $0 $1,548 $108 $14 $0 $0

145062 Johnson, Robert E 3 1.174 $3,231 $0 $540 $2,691 $41 $0 $0

145546 Johnson, Robert A 3 0.083 $3 $0 $0 $3 $0 $0 $0



Provider Service Utilization Analysis with



Avg PI Risk

Score

IP Admits P1kMPY

IP Avg LOS

ER Visits (PMPY)

Office Visits

(PMPY)

Referrals

(PMPY) Lab Tests

(PMPY) Rad Units

(PMPY) Ther Units

(PMPY)

106 203 0.733 7 162.6 0.4 0.7 0.2 .08 2.9 1.2 1.1

Provider ID Provider Name Panel Avg DB PI

Risk Score

IP Admits P1kMPY

IP Avg LOS

ER Visits (PMPY)

Office Visits

(PMPY)

Referrals

(PMPY) Lab Tests

(PMPY) Rad Units

(PMPY) Ther Units

(PMPY)

143303 Hancock, Joan K 7 0.298 8 142.9 0.4 0.9 1.0 2.1 0.9 1.7 0.1

146844 Harris, Rosemary A 6 0.536 6 0.0 0.0 0.0 1.2 0.0 1.8 0.0 7.7

150251 Hancock, Joan P 1 1.602 5 0.0 0.0 0.0 2.0 0.0 0.0 3.0 0.0

153545 Hancock, Joan J 4 1.130 7 0.0 0.0 0.5 0.0 0.0 18.0 14.8 0.0

142446 Johnson, Robert D 1 0.186 4 0.0 0.0 0.0 7.0 0.0 0.0 0.0 0.0

151397 Hancock, Joan L 1 3.586 11 0.0 0.0 3.0 2.0 3.0 6.0 6.0 3.0

153519 Hancock, Joan R 5 0.111 7 0.0 0.0 0.6 0.4 0.0 3.0 1.2 0.2

146668 Johnson, Robert L 1 0.077 12 0.0 0.0 1.0 4.0 2.0 9.0 0.0 0.0

140333 Hancock, Joan R 1 0.236 10 0.0 0.0 3.0 1.0 0.0 4.0 1.0 0.0

146318 Johnson, Robert J 1 1.603 13 0.0 0.0 1.0 3.0 0.0 3.0 1.0 0.0

146603 Hancock, Joan L 6 4.536 18 166.7 1.0 0.8 3.0 2.0 0.7 1.3 0.0

152220 Johnson, Robert C 7 0.105 3 428.6 2.0 0.9 0.0 0.0 1.3 0.4 0.0

145671 Hancock, Joan L 9 0.464 4 111.1 1.1 2.4 1.1 1.0 1.6 0.6 0.9

146910 Harris, Rosemary S 3 0.801 7 100.0 1.3 0.7 0.0 1.0 6.0 2.7 0.0

150310 Johnson, Robert H 1 0.841 6 0.0 0.0 2.0 0.0 0.0 7.0 4.0 0.0

143792 Johnson, Robert P 3 1.977 12 333.3 0.3 8.0 1.0 0.3 2.7 3.7 0.0

146378 Johnson, Robert M 1 0.920 8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

142647 Hancock, Joan H 5 0.276 3 0.0 0.0 0.2 0.8 1.0 1.4 0.2 0.0




Avg PI Risk

Score

IP Admits P1kMPY

IP Avg LOS

ER Visits (PMPY)

Office Visits

(PMPY)

Referrals

(PMPY) Lab Tests

(PMPY) Rad Units

(PMPY) Ther Units

(PMPY)

106 203 0.733 7 162.6 0.4 0.7 0.2 .08 2.9 1.2 1.1

Provider ID Provider Name Panel Avg DB PI

Risk Score

IP Admits P1kMPY

IP Avg LOS

ER Visits (PMPY)

Office Visits

(PMPY)

Referrals

(PMPY) Lab Tests

(PMPY) Rad Units

(PMPY) Ther Units

(PMPY)

146216 Johnson, Robert K 4 1.258 12 0.0 0.0 1.3 0.0 0.3 1.3 2.5 0.0

153674 Harris, Rosemary J 6 0.378 10 166.7 0.8 1.0 0.0 1.2 4.0 2.2 0.0

145062 Johnson, Robert E 3 1.174 9 0.0 0.0 0.7 0.0 0.0 3.7 0.0 0.0

151482 Johnson, Robert M 1 0.236 1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0



Provider Pharmacy Analysis with



Rx Scripts (PMPY)

Generic % Brand Name % Rx Cost (PMPY)

106 203 0.733 11.8 58.5 41.5 $553

Provider ID Provider Name Panel Avg DB Rx

Scripts (PMPY)

Generic % Brand Name % Rx Cost (PMPY)

151397 Hancock, Joan L 1 3.586 88.0 54.5 45.5 $5,049

143303 Hancock, Joan K 7 0.298 3.9 88.9 11.1 $17

153545 Hancock, Joan J 4 1.130 11.3 66.7 33.3 $198

150251 Hancock, Joan P 1 1.602 118.0 60.2 39.8 $3,969

146668 Johnson, Robert L 1 0.077 3.0 100.0 0.0 $0

142446 Johnson, Robert D 1 0.186 5.0 0.0 100.0 $209

153519 Hancock, Joan R 5 0.111 3.0 46.7 53.3 $42

146844 Harris, Rosemary A 6 0.536 12.2 65.8 34.2 $708

150310 Johnson, Robert H 1 0.841 20.0 25.0 75.0 $891

145671 Hancock, Joan L 9 0.464 10.3 78.5 21.5 $690

146378 Johnson, Robert M 1 0.920 7.0 71.4 28.6 $614

146603 Hancock, Joan L 6 0.536 3.0 83.3 16.7 $19

140333 Hancock, Joan R 1 0.236 19.0 36.8 63.2 $0

146318 Johnson, Robert J 1 1.603 43.0 93.0 7.0 $2,927

143792 Johnson, Robert P 3 1.977 23.3 80.0 20.0 $1,519

152220 Johnson, Robert C 7 0.105 0.9 50.0 50.0 $0

146910 Harris, Rosemary S 3 0.801 3.3 100.0 0.0 $123

145062 Johnson, Robert E 3 1.174 21.0 61.9 38.1 $2,691

146216 Johnson, Robert K 4 1.258 38.5 57.8 42.2 $2,853

153674 Harris, Rosemary J 6 0.378 7.2 48.8 51.2 $106

145546 Johnson, Robert A 3 0.083 2.0 100.0 0.0 $3

141808 Johnson, Robert R 1 0.106 20.0 60.0 40.0 $0

Documents

Email Address: Telephone: (304) 222-0000 State of West ... · State of West Virginia DW/DSS Bureau for Medical Services RFP MED11015 ... Burden: 4.530 Name: Smith, Jane R Disease(s):