The Dangers of Anarchic Growth in Healthcare Spending:
Factors such as advances in medical science, the emergence of new therapies, and the epidemiological shift toward aging populations with a higher prevalence of chronic diseases are dangerously driving up healthcare spending.
In many cases, it is increasingly common to hear that the sustainability of healthcare systems is at risk because this growth in spending does not follow logical parameters but rather takes on an anarchic nature.
According to international evidence, up to 40% of healthcare spending is avoidable with technology and processes such as Value-Based Healthcare (VBH). Designing and planning user-centered health systems with aligned incentives between payers and providers has proven to be the best paradigm for achieving efficiency and equity
(Value-Based Healthcare)
- Unnecessary Procedures
- Diagnostic Errors
- Redundant Treatments
- Prolonged Hospitalizations
- Ineffective Medications
- Prevention Failures
- Operational Inefficiencies
We Improve Clinical, Economic, and Population Indicators
Value Proposition
At AVEDIAN, we develop specific technology that, when combined with Diagnosis-Related Groups (DRGs), enhances critical aspects for health insurance by enabling greater governance of healthcare spending:
- Data Integration and Standardization: Utilizing DRG methodology to streamline data.
- Population Module: For monitoring care pathways and identifying insured individuals at clinical and/or economic risk.
- Clinical Management Modules: To measure the efficiency of the provider network, optimize resources, and detect waste.
- Economic Management Modules: Through DRG-based payment models to achieve shared risk between providers and insurers.
- Data Governance Modules: To ensure the quality and security of information.
360° Strategic Information
Using international methodologies, we analyze hospital case studies and costs, apply benchmarking, and use AI to suggest the best care processes for each patient profile.
At AVEDIAN, we develop specific technology that integrates and standardizes all clinical, care, and economic information generated in hospitals using DRG (Diagnosis-Related Groups) methodology.
The result is strategic and relevant information for any decision-maker, providing 360° evidence on the organization through dashboards ranging from simple to complex.
The involvement of management areas in the continuous improvement of results drives operational excellence in clinics and hospitals.
Pain Points We Address
- Data Fragmentation: Both clinical and economic.
- Challenges in Data Governance and Regulatory Compliance.
- Lack of Clear Understanding of Population Health within the insured portfolio.
- Insufficient Information to Track the Evolution of Population Health in the portfolio and to take action accordingly.
- Inability to Identify High-Risk Insured Individuals.
- Lack of Data to Segment Insured Individuals by Clinical Similarity and Detect Frequent Consumption Patterns.
- Difficulty in Defining Care Pathways for Insured Individuals with Chronic Diseases.
- Inability to Effectively Detect Waste within the Care Network.
- Lack of Information for Defining Pricing Based on Insured Risk.
- Limited Understanding of the Efficiency of the Medical Provider Network.
- Lack of Information for Negotiating Contracts with the Medical Provider Network.
- Insufficient Tools to Manage Insured Care Pathways.
- Difficulty in Identifying Areas for Improvement.
- Difficulty in Measuring the Impact of a Decision or Action Plan.
New Contracting and Payment Models
Fee-for-service payment has proven to be ineffective in balancing cost control and promoting improvements in population health. Additionally, fee-for-service encourages high levels of waste (also known as avoidable spending) because the incentives are aligned with overbilling of services.
In contrast, Outcome-Based Payment Models with DRG modules are the gold standard in the most developed healthcare systems worldwide. These models minimize waste in usage rates by better aligning interests with provider networks, effectively controlling costs while promoting a care approach focused on achieving the best possible outcomes.
Access to High-Cost Medications
The prices of new medications continue to rise, outpacing inflation and affordability. Health insurers seek to manage this increase while ensuring equitable access. A growing solution is value-based purchasing of medications, where costs are tied to outcomes. Payers pay more for effective treatments and can replace ineffective medications, incentivizing pharmaceutical companies to improve treatment effectiveness. Additionally, this approach generates more data on drug effectiveness, which facilitates the development of new treatments.
Population Risk Management
The phenomenon of epidemiological transition requires a proactive approach based on evidence and clinical guidelines. Understanding the patient journey and designing a user-centered value proposition are key for organizations managing patient populations.
Advanced analytics with integrated, standardized, homogeneous, and comparable data allows for effective population risk management, creating a preventive approach that helps control healthcare spending.
Our Products and Services
For Health Insurance
Hospital Outpatient DRG Aggregator
DRGs (Diagnosis-Related Groups) are patient classification systems that group episodes through rules and algorithm engines based on clinical similarity and resource consumption criteria.
What Does It Allow Insurers to Achieve?
- Advanced hospital analytics compared to standards.
- Benchmarking of the provider network.
- Referral of cases to the most efficient providers.
- Measurement of the resolution capacity of primary care.
Population Risk Aggregator
These tools classify, measure, analyze, and explain the clinical and economic risk of groups within a population, making it easier for decision-makers to implement strategies to improve population health.
What Does It Allow Insurers to Achieve?
- Monitoring and evolution of the insurance portfolio.
- Defining commercial strategies to attract new insured individuals.
- Planning annual prevention programs.
- Identifying and tracking members at clinical and/or economic risk.
- Monitoring chronic patients.
BRMS - Business Rules Management System
An advanced tool for managing business rules used in decision-processing systems within complex environments.
What Does It Allow Insurers to Achieve?
- Fully customizable rules to be applied at the time of service, during service, or upon completion, generating a pre-billing process.
Datalake
A centralized repository that allows the storage of all structured and unstructured data at any scale.
What Does It Allow Insurers to Achieve?
- Unify all information sources from different systems.
Advanced BI Analytics
Dynamic analytical dashboards that allow information to be approached from different perspectives, facilitating internal organization to develop reports on all structured variables within the systems.
What Does It Allow Insurers to Achieve?
- Track key management indicators.
- Measure the performance of the provider network.
- Monitor medication consumption and its relationship to declared pathologies.
- Fraud detection.
AVIA - AI Solutions Lab
The AI solutions lab, AVIA, not only optimizes the operational efficiency of hospitals and insurers but also supports value-based healthcare models, focusing on improving patient outcomes, reducing costs, and ensuring the sustainability of the healthcare system.
What Does It Allow Insurers to Achieve?
- Integrate and analyze information from various sources to improve decision-making, optimize operations, and generate better clinical and economic outcomes.
- AVIA centralizes fragmented and unstructured data from systems such as memberships, medical auditing, billing, and more, providing a comprehensive view of patients’ health status. Using international methodologies like DRGs, the platform standardizes and classifies medical episodes, facilitating the identification of consumption patterns, inefficiency detection, and predictive analysis.
- Application of computer vision models for data extraction from images, files, or documents with unstructured formats.
Contracting and Payment Platform (PCP)
The “patient journey” or care process includes at least three instances requiring specific decisions, all managed on the same platform.
What Does It Allow Insurers to Achieve?
- Eligibility: for both coverage eligibility and the provider agreement to deliver care.
- Authorization Order Request Flow
- Length of Stay Estimations: (hospitalization)
- Coding: detailing service consumption and episode diagnoses.
- Pre-billing: DRG calculation and episode valuation.
What Does It Allow Insurers to Achieve?
What Does It Allow Insurers to Achieve?
- Choose the best valuation process.