Payors / cost of care
Explain the Trend Before the Meeting
A PMPM spike is three changes pretending to be one. Ana splits utilization, price and mix, follows the trend to the members, providers and sites of care behind it, and hands medical economics the driver with the claims attached.
The Trend Meeting, Before and After
- A PMPM spike waits a month for a report request
- Utilization, price and mix argued from different extracts
- Drill-downs stop at the dashboard’s edge
- IBNR and forecasts rebuilt by hand each close
- The spike arrives with its drivers already found
- Every change decomposed from one model of the plan
- Follow any trend to the member and the claim line
- Forecasts refreshed from the same claims, on schedule
Split Every Trend Into What Actually Moved
A PMPM change is three changes pretending to be one. Ana walks every trend from last year to this one — utilization, unit price, service mix, site of care — from the same claims, eligibility and contracts, so the conversation starts from the driver, not the total.
- Trend watch runs weekly, across every line of business
- Drivers ranked by dollars, not by row count
- Member months, allowed and paid reconciled to finance
Not More Scans — the Same Scans at Hospital Prices
The dashboard says imaging is up 18%. The claims say volume is flat: one radiology group joined a hospital system, and the same MRIs are now billed as hospital outpatient. Every driver arrives split into utilization, price and mix, with the claims behind it.
- Each driver arrives with its members and claims
- Price effects tied to the contract in force
- Mix shifts by setting, service line and provider
- q3 Imaging PMPM — commercial all lines · 412k members $14.20
- q3 Year-over-year change same members · same benefits +$2.17
Turn the Driver Into a Decision
A driver is only useful if someone can act on it. Ana sizes the opportunity from the same claims — which members, which centers, what it saves — and writes it up for the team that will act.
- Opportunities sized from the same claims
- Briefs written for network, care and finance teams
- Results tracked after the change lands
- q3 MRIs billed as hospital outpatient npi group 1629 · 2,568 scans $1,240 avg
- q3 PMPM added by the shift same members · same benefits +$1.90
- client
- profile
- health plans · health systems · medical groups
- workload
- claims forecasting · pmpm · cost trend
- environment
- hipaa · private cloud · redshift
- manual on demand executive pmpm and cost-trend reports
- 2–3 day wait 0 analyst on-call for ad-hoc reports
PMPM and cost-trend reporting on demand, and claims forecasting cut from days to minutes.
Before TextQL, it took users multiple steps trudging through a number of reports in order to connect the dots and find where the opportunities and insights lie. Now, they no longer have to do that.
Start With the Trend on This Quarter’s Slide
The first run looks back over a year of claims, so the drivers are sized in dollars before anyone changes a program. The ones that hold up become a weekly watch.
Explain a Trend
Bring the one on this quarter’s slide. We run it against a year of your claims, inside your cloud, and walk medical economics through what actually moved.
- 01A 30-minute call to pick the trend and the claims in scope
- 02We connect inside your cloud under a BAA — nothing leaves your environment
- 03Your team checks every driver against its own claims
Where Medical Economics Starts
- 01 Trend decomposition
Split every PMPM change into utilization, unit price and mix, by line of business, region and service category.
- 02 High-cost claimants
Track the members driving the top of the curve, what is driving them, and which are rising before they cross a threshold.
- 03 Site-of-service steerage
Find the services moving to higher-cost settings and the members and referrers behind them.
- 04 Specialty and pharmacy spend
Follow drug spend across medical and pharmacy benefits, including biosimilar adoption and J-code mix.
- 05 Value-based contract performance
Measure attributed spend against shared-savings targets as claims arrive, not after reconciliation.
- 06 Claims forecasting and IBNR
Refresh completion factors and forecasts from the same claims on a schedule, instead of rebuilding them each close.
Read access, inside your environment, to a year of medical and pharmacy claims, eligibility and the contracts in force. Your team picks the trend; we decompose it and walk medical economics through the drivers.