Wakely Risk Insight (WRI)

Understanding profitability in the individual and small group (ACA) markets.

It is impossible to manage what you cannot measure, and measuring performance in the risk adjusted environment is now more challenging than ever. We used to be able to look at drivers of cost in order to gain insight into the experience. In a risk adjusted environment, drivers of profitability can be counter intuitive; for example, the older, sicker, and costlier individuals may actually be improving the financial performance of the plan, rather than impairing it.

Wakely Risk Insight (WRI) performs two key functions. It allocates important financial items such as risk adjustment transfers, fees and taxes, etc. at the member level. Secondly, it applies a sophisticated slicing and measuring algorithm to isolate drivers of profitability for further analysis.

The reporting includes:

  • Information from public data sources on state and carrier profitability and competitive positioning
  • Analysis and comparison of your organization’s profitability by:
    • Demographics
    • Metallic tier
    • Hierarchical Condition Categories (HCCs)
    • New vs. existing enrollees
    • On/off exchange
    • Claim cost deciles and quartiles
    • Rating area
    • Renewal quarter or partial enrollment
  • Regional benchmarks that include:
    • High level utilization and unit cost by service categories
    • Impact of supplemental diagnosis codes (from chart reviews) for your organization vs. sampled average
    • Utilization of specialty/high-cost drugs for your organization vs. sampled average
    • Prevalence and net income by each individual HCC for your organization vs. sampled average
  • New in 2020: COVID-related exhibits, including:
    • Prevalence in population, including testing
    • Stratification of cases by severity (including hospitalization, days of stay, ICU/ventilator usage)
    • Utilization and unit costs
    • Year-over-year comparison to detect potentially deferred care
    • Specific drug usage (e.g. Remdesivir)
    • Comparisons and benchmarks (once enough data is available)

One of the keys of WRI is the allocation of key financial amounts (e.g. taxes, fees, risk adjustment transfers, other adjustments) at the member level. The member-level file with allocated amounts is available to the client as well. Once amounts are allocated, a sophisticated algorithm similar to a decision tree searches through various member segments to calculate their relative importance in driving plan profitability. In this manner the key drivers of profitability are revealed and can be monitored over time.

Wakely has unique data assets, including one with over ten million ACA lives. We have crafted key regional benchmarks that are included in the WRI exhibits for useful comparisons.

In the WRI analytics, we examine a number of hypothesis to see if there are any obvious drivers of profitability for a given health plan. The standard set that we test includes demographics, metallic tiers, medical conditions or HCCs, rating area, quartiles of cost, etc. In addition, we have the flexibility to test client-specific inputs such as profitability by acquisition channel, providers, hospital networks, etc.

WRI is not static. We constantly curate the exhibits to make them relevant, useful, and effective. For example, in 2020 we added new exhibits related to COVID. There are also important regulatory changes (e.g., state-based reinsurance programs) that have important financial implications for sections of the ACA population. 

Unique products and tools.

Wakely has developed these industry-leading products and tools, which empower our clients to make highly informed strategic decisions.

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Wakely Medicare Advantage Competitive Analysis Tool (WMACAT)

Allows health plans to compare Medicare Advantage benefits and market information at the national, state, and county levels, to evaluate plan design and performance.

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Wakely National Risk Adjustment Reporting (WNRAR)

Provides risk adjustment metrics from 35 states and 19 million lives.

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Risk Score Opportunities (RSO)

Identifies and prioritizes members who are most likely to have a condition that has not been coded.

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Wakely Plan Valuation Model (WPVM)

Supports pricing, mental health parity compliance, cost and utilization analysis and more.

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Risk Adjustment Payment & Identifying Discrepancies (RAPID)

Gets the most out of your EDGE data.

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Wakely Analytics Health Operations Optimization (WAHOO)

Helps payers and providers optimize financial performance with a complete package of services and tools.

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Wakely Affordable Care Act Competitive Analysis Tool (WACACAT)

Allows users to interactively explore market metrics.

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Wakely Risk Assessment (WRA)

Provides a transparent, open-code, high-performance risk assessment model.

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Wakely Risk Insight National Reporting Project (WRINR)

Identifies key profitability drivers for the individual and small group markets.

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Wakely Medicare Repricing Analysis Tool (WMRAT)

Aids the comparison of payment rates across multiple lines of business, categories of service, geographic locations, and providers.

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Wakely ACA Database (WACA)

Contains the most robust and detailed ACA data available in the industry.

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Risk Adjustment Data Integrity Analysis & Lineage (RADIAL)

Compares multiple data sources to provide transparency in risk score differences.

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Risk Adjusted Payments & Identifying Discrepancies for Medicare Advantage Plans (RAPID-M)

Helps plans optimize risk scores by identifying RAPS and EDS inconsistencies

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