MedCity News on CliniCast ARTO

Great article by Deanna Pogorelc at MedCity News on CliniCast and how our risk scores are particularly well suited for the new world of healthcare.



Risk-Adjustment : Using Data to Personalize Insurance Payments

The widespread adoption of risk-adjustment methodologies is among the most interesting aspects of health reform. Risk-adjustment refers to the process of matching payment for patient care to expected costs, factoring in information about the patient’s demographics, diagnoses and previous utilization. By providing greater payments for sicker, more costly patients, these methodologies better balance the payment and cost of patient care. While Medicare Advantage and certain Medicaid plans have used risk-adjustment for years, these methodologies are primed for widespread adoption in health insurance exchanges and commercial plans.


Risk adjustment depends crucially on an objective assessment of the patient’s health, usually gleaned from electronic health data. Individuals with expected health spending significantly higher than average are considered to be “high risks”. Data sources commonly include pharmacy, outpatient and inpatient claims.


Risk adjustment depends crucially on accurate data collection in order to appropriately calibrate payment : data manipulation breaks the balance between cost and payment and opens the door to gaming. Including diagnostic data significantly reduces the opportunity for gaming.


At CliniCast, we believe that comprehensive risk scores based on claims, medications, and laboratory data offer the greatest resolution on a patient’s expected costs, and therefore the best opportunity to balance potential payment. If you would like to know how our risk scores could support your risk adjustment efforts, please reach out to us at or visit our website at


To learn more:

 Health Affairs has an excellent policy brief that explains risk-adjustment in detail.

 The American Academy of Actuaries has a very intelligent article on the issue.

 Finally, the Center on Budget and Policy Priorities has an excellent writeup on the new horizons for risk-adjustment.


Future of Healthcare

The Future of Healthcare

At CliniCast, we like to think about where healthcare is going. Jack even gave a talk on the subject a few months ago:

A brief summary for the time-pressed:

By any measure, the US healthcare system is simply unsustainable . The inexorable growth in the cost of care means that healthcare eats an ever growing fraction of the nation’s wealth, becoming increasingly unaffordable to the majority of Americans. While the Affordable Care Act presents a first step forward, there is much left to improve.

At CliniCast, we believe that the shift in financial risk from payers to providers presents an opportunity to be smarter about patient care. Health IT can help providers better communicate, coordinate care and share information. This is about building a better overall system rather than individual therapies (like drugs).

How might healthcare change in the future:

    • More Standardization. Interoperable standards will lead to more innovation solutions around analytics, billing, visualization and services. Like with PCs, the underlying platform will matter less and less.
    • Quantification of Risk. Providers will start using tools like individualized risk scores to prioritize patients, match patients to appropriate interventions, measure the effectiveness of interventions and benchmark performance.
    • Automated Decision-Making. Individualized risk scoring, with standardized business rules will increasingly streamline decision-making. Watson’s work in streamlining preauthorization for Wellpoint is just a first example of this.
    • More clinical extenders. Nurse practitioners, physician assistants, care managers and medical assistants will increasingly take on the duties of care for nurses and physicians. This is a good thing.
    • Inpatient → Ambulatory → Home. For many patients, home presents an ideal setting of care. The falling cost of medical technology and the rising cost of inpatient management makes managing patients at home an increasingly attractive option. The explosion in home health will be one of the “surprises” of the next two decades.


At CliniCast, we always like to think about how data will revolutionize care. If you would like to continue the discussion, please reach out to us at


Optimize Outcomes, Minimize Costs

Healthcare providers are becoming increasingly accountable for the Triple Aim of patient care: better patient outcomes, improved patient wellbeing, lowering patient cost. Matching the right patient to the right intervention at the right time in this environment is challenging, requiring balancing tradeoffs between resources and outcomes.

At CliniCast, our ARTO suite helps customers thrive in this environment by proactively managing their patients, identifying those patients for whom early interventions can prevent future hospitalizations. By leveraging their data assets for real population management, our customers can better identify their highest risk patients, better match those patients to appropriate interventions, measure ROI based on those interventions, and benchmark staff performance.

ARTO is particularly designed with the care manager in mind, to help him or her streamline workflow and decision-making. By highlighting high risk patients and prioritizing their care gaps, each care manager can deliver better quality care to a larger number of patients.

To learn more about ARTO, please see our video here:

All of us at CliniCast are committed to enabling our customers to deliver better patient health at a lower cost. If you think we could help your organization succeed, please contact us at .