Abstract:
A high-performance capability assessment model helps a health and life sciences business meet the challenges of the global marketplace. As a result, the health and life sciences business can achieve the clarity, consistency, and well-defined execution of core processes that reduce inefficiencies and waste that result from unnecessary process complexity and exceptions. In addition, the high-performance capability assessment model helps the health and life sciences business to identify specific areas in which improvements may be made, to understand how to make said improvements, and to establish levels of capability along the way to reaching an ultimate capability goal.

Description:
BACKGROUND OF THE INVENTION 
     1. Technical Field 
     This disclosure concerns a system and method to identify the performance of an organization on a scale of mastery across representative capabilities of the organization&#39;s industry. In particular, this disclosure relates to an efficient and cost effective way to assess the performance level of key capability areas within the processes of a health and life sciences organization, and in particular a payer in a health and life sciences organization. 
     2. Background Information 
     Modern health and life sciences organizations operate in an increasingly challenging environment. To survive, health and life sciences organizations must adapt to this environment and execute in a clear, consistent, and efficient manner. Furthermore, the competitive nature, regulatory requirements, low profit margins, and competitive challenges of health and life sciences businesses greatly increase the complexity and difficulty of surviving on a day-to-day basis. 
     Despite the need for a health and life sciences organization to meet the challenges of the global marketplace, it is still often the case that the business lacks clarity, consistency, and well-defined execution of its core processes. These shortcomings severely constrain the business, and lead directly to inefficiencies and waste due to unnecessary complexity, process exceptions, and customer dissatisfaction. At the same time, it can be very difficult to identify specific processes to which improvements may be made, either because the business itself does not have the expertise to identify the processes or because the complexities of the business frustrate attempts to clearly delineate the processes to be improved. 
     Even if the health and life sciences business, on its own, could identify one of the many processes that it needs to improve, the business would not necessarily know how to improve the process or be able to identify a concrete and measurable improvement goal. Another difficulty exists in determining whether there are any intermediate goals that should be reached along the way. As health and life sciences businesses struggle to meet the demands of the modern economic landscape, they fail to identify opportunities for maximizing sales and margin improvement, category expansion, multi-channel execution, customer satisfaction improvement, and to reach other important goals. 
     Therefore, a need exists for an efficient and effective system and method to assess the performance level of key assessment areas within the processes of an organization. 
     SUMMARY 
     A high-performance capability assessment (HPCA) model helps health and life sciences businesses meet the challenges of the global marketplace by defining a scale of performance mastery along which the current practices of the business may be located. The HPCA model accelerates the discovery of process and performance gaps within business operations. In addition, the HPCA model also helps the business to identify specific areas in which improvements may be made, how to make the improvements, and how to establish performance measures during the course of attempting to achieve an ultimate goal. As a result, the business can achieve the clarity, consistency, and well-defined execution of core processes that maximize the operating budget for optimum outcomes. 
     The HPCA model includes a key factor dimension and a performance mastery scale dimension. The performance mastery scale dimension defines multiple mastery levels. The performance mastery levels form a scale of increasing organizational performance. The scale includes a ‘Basic’ mastery level, a ‘Competitive’ mastery level, and a ‘Market Leading’ mastery level along a horizontal axis. Each performance mastery level includes criteria specific to a corresponding key assessment area. Each key assessment area identifies some aspect of a capability of a health and life sciences business with respect to a payer organization, such as for example, an insurance company when dealing with the private sector. 
     A business capability can be defined as a bundle of closely integrated skills, knowledge, technologies, and cumulative learning that is exercised through a set of processes and that collectively represents an organization&#39;s ability to create value by producing outcomes and results. Capability areas do not represent a delineation of organizational responsibilities as the business outcomes of a capability may be the result of a number of cross-functional teams. Capabilities of a business may be grouped into areas and/or platforms, including platforms and sub-platforms, depending on the organizational structure of the business. 
     For example, the HPCA model groups the capabilities of the health and life sciences industry for a payer into five main areas or high-level platforms, which may also be thought of as “business areas,” namely a direct and guide the organization platform, a develop and maintain market platform, a coordinate health care services platform, a manage operations platform, and a support the organization platform. Each platform includes multiple platforms and/or sub-platforms. For example, the coordinate health care services platform may include four sub-platforms, namely a perform health care management sub-platform, a develop and manage networks sub-platform, a service the networks sub-platform, and a manage pharmacy sub-platform. 
     Some of the platforms and sub-platforms may include additional or further sub-platforms or granularity, while others may not, and may also include capabilities at their lowest level. Examples of capabilities within the perform health care management sub-platform, include for example, design and incentives capabilities, segment and target capabilities, reach and engage capabilities, collaborate and support capabilities, evaluate and improve capabilities, and a cross-core functions capabilities. 
     The key factor dimension establishes a set of key assessment areas in which to analyze the capabilities of a business. Key assessment areas include performance capability criteria. Performance capability criteria populate the performance capability assessment model. The performance capability criteria may be specific to any one of many different business capabilities. Any number of performance capability assessment models and performance capability criteria may be defined and stored in a capability detail pool for subsequent retrieval and application to a business under examination. Accordingly, the HPCA model provides a flexible and adaptive scale of performance capability against which business practices may be compared to ascertain where the capabilities of a business under examination fall along the scale. 
     Other systems, methods, features, and advantages will be, or will become, apparent to one with skill in the art upon examination of the following figures and detailed description. All such additional systems, methods, features, and advantages are included within this description, are within the scope of the invention, and are protected by the following claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The health and life sciences industry high-performance capability assessment model and system may be better understood with reference to the following drawings and description. The elements in the figures are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the capability assessment techniques. In the figures, like-referenced numerals designate corresponding parts throughout the different views. 
         FIG. 1  shows a high-performance capability assessment model with a performance scale of mastery and performance criteria shown for different capabilities showing multiple platforms, including a direct and guide the organization platform, a develop and maintain market platform, a coordinate health care services platform, a manage operations platform, and a support the organization platform. 
         FIG. 2  shows a high-performance capability assessment model with capabilities for sub-platforms including a perform health care management sub-platform, a develop and manage networks sub-platform, a service the networks sub-platform, and a manage pharmacy sub-platform, all corresponding to the coordinate health care services platform. 
         FIG. 3  shows a high-performance capability assessment model with capabilities for design and incentives, segment and target, reach and engage, collaborate and support, evaluate and improve, and cross-core functions, all corresponding to the perform health care management sub-platform. 
         FIG. 4  shows a high-performance capability assessment model with further capabilities corresponding to design and incentives. 
         FIG. 5  shows a high-performance capability assessment model with further capabilities corresponding to segment and target. 
         FIG. 6  shows a high-performance capability assessment model with further capabilities corresponding to reach and engage. 
         FIG. 7  shows a high-performance capability assessment model with further capabilities corresponding to collaborate and support. 
         FIG. 8  shows a high-performance capability assessment model with further capabilities corresponding to evaluate and improve. 
         FIG. 9  shows a high-performance capability assessment model with further capabilities corresponding to cross-core functions. 
         FIG. 10  shows a capability detail pool providing a multidimensional health and life sciences industry performance reference set where multiple key assessment performance reference tables are collected and stored. 
         FIG. 11  shows a capability assessment system. 
         FIG. 12  shows a flow diagram for establishing high-performance capability assessment models. 
         FIG. 13  shows a flow diagram for retrieving and applying high-performance capability assessment models. 
         FIG. 14  shows a flow diagram for analyzing representative practice data to determine a health and life sciences industry and a health and life sciences key assessment area to which the representative practice data applies. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
       FIG. 1  shows a high-performance capability assessment (HPCA) model  100 . The HPCA model  100  specifies five platforms, including a direct and guide the organization platform  102 , a develop and maintain market platform  104 , a coordinate health care services platform  106 , a manage operations platform  108 , and a support the organization platform  110 . Each platform  102 ,  104 ,  106 ,  108  and  110  may include sub-platforms. The HPCA model  100  is not limited to the form shown in  FIG. 1 . Instead, the HPCA model  100  may be adapted and modified to fill a wide variety of analysis roles. Additional, different, or fewer platforms may be used in other implementations, with each platform defining additional, different, or fewer capabilities. Each platform and/or sub-platform includes one or more multiple &lt;platform/sub-platform name&gt; capabilities  130 . 
     The HPCA model  100  establishes a multidimensional health and life sciences industry performance reference set that includes multiple key assessment performance levels  138 , further described below in reference Tables 1-3. The performance levels  138  establish a scale of increasing effectiveness in delivery of each capability. The key assessment performance reference tables include a ‘Basic’  140  delivery level, a ‘Competitive’  142  delivery level and a ‘Market Leading’  144  delivery level. The performance levels establish a scale of mastery  146  along which current business practices may be located and identified with respect to any platform and capability within a platform according to an analysis of performance capability criteria (PCC). The capability under evaluation may be assigned the performance level  138  based on a delivery effectiveness position  158  along the scale of mastery  146 . 
     The ‘Basic’ delivery level  140  specifies ‘Basic’ performance assessment criteria, the ‘Competitive’ delivery level  142  specifies ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ delivery level  144  specifies ‘Market Leading’ performance assessment criteria. The HPCA model  100  receives input data that specifies a health and life sciences business platform (e.g., a health and life sciences industry area) and a health and life sciences industry key assessment area for analysis. The HPCA model  100  searches the multidimensional health and life sciences industry performance reference set for a matching key assessment performance reference table that matches the health and life sciences industry platform and corresponding industry capability within the platform and the health and life sciences industry key assessment area, and retrieves the matching key assessment performance reference table. The HPCA model  100  initiates analysis of the matching key assessment performance reference table to obtain a resultant performance assessment level for the health and life sciences industry key assessment area. 
     Tables 1-3 below provide an explanation of each of the capability levels  140 ,  142 , and  144 . 
     
       
         
               
             
               
               
             
           
               
                 TABLE 1 
               
               
                   
               
               
                 ‘Basic’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Description: 
                 Capability mastery at the basic level is competitive on a  
               
               
                   
                 domestic or local level and selectively on a global basis. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
           
               
                 TABLE 2 
               
               
                   
               
               
                 ‘Competitive’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Description: 
                 Capability mastery at a competitive level is in the top  
               
               
                   
                 50% of performers when compared to domestic and  
               
               
                   
                 international peer groups. 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
           
               
                 TABLE 3 
               
               
                   
               
               
                 ‘Market Leading’ Delivery Level 
               
               
                   
               
             
             
               
                   
               
             
          
           
               
                 Description: 
                 Capability mastery at a market leading level implies that  
               
               
                   
                 few companies globally are performing at this level, and  
               
               
                   
                 can include emerging capabilities where companies have  
               
               
                   
                 committed significant levels of investment and resources. 
               
               
                   
               
             
          
         
       
     
     For  FIGS. 2-9  the capability under evaluation may be assigned a level of mastery  138  based on the business&#39; position along the scale of mastery  146  (e.g., the ‘basic,’ ‘competitive,’ or ‘market leading’ delivery level). Performance criteria corresponding to the basic  140 , competitive  142 , and market leading  144  performance levels populate the HPCA model  100 . The performance criteria capture characteristics, and/or other features of the delivery of a capability at a particular performance level. Examples below illustrate performance criteria that provide analysis and benchmarking for health and life sciences organizations. The HPCA model  100  performance criteria provide a tool for determining where a platform and capability under examination falls along the scale of mastery  146 . 
     For example, business consultants and business process engineers may interview a business or receive data about the business to determine, measure, or otherwise ascertain the characteristics, criteria, and other features of a particular capability implemented within the business. The consultants and engineers may compare the characteristics of the business to the performance criteria in the HPCA model  100  and arrive at an assessment level  138  for the capability under examination. In doing so, for example, the consultants and engineers may identify where the capability under examination falls in terms of the performance level for each key assessment area of a capability and determine an overall position on the scale of mastery  146  for the capability under examination. Performance criteria may populate the HPCA model  100  in whole or in part. Multiple high-performance capability assessments may be collected and stored with the performance criteria for future retrieval and possible modification in a capability detail pool, discussed below. 
       FIG. 2  shows the coordinate health care services platform  106  divided into respective capability areas  202 . The coordinate health care services platform  106  includes a perform health care management sub-platform  220 , a develop and manage networks sub-platform  222 , a service the networks sub-platform  224 , and a manage pharmacy sub-platform  226 . 
       FIG. 3  shows the perform health care management sub-platform  220  (corresponding to the coordinate health care services platform  106 ) divided into respective capability areas  302 . The perform health care management sub-platform  220  includes a design and incentives capability  320 , a segment and target capability  322 , a reach and engage capability  324 , a collaborate and support capability  326 , an evaluate and improve capability  328 , and a cross-core functions capability  330 . 
       FIGS. 4-9  show the capabilities associated with the sub-platform entitled perform health care management  220 . The capabilities associate with the develop and manage networks sub-platform  222 , service the networks sub-platform  224 , and manage pharmacy sub-platform  226  are not shown in this document.  FIG. 4  shows further capabilities  402  including a design and innovative products capability  420 , a design services capability  422 , and a design campaigns capability  424 . 
       FIG. 5  shows further capabilities  502  including a project population health and wealth indicators capability  520 , and an identify individual intervention opportunities capability  522 . 
       FIG. 6  shows further capabilities  602  including a perform proactive and reactive outreach capability  620 , a provide inbound advisory services capability  622 , a coordinate care capability  624 , a promote optimal lifestyle capability  626 , and a provide decision support capability  628 . 
       FIG. 7  shows further capabilities  702  including an engage provider capability  720 , and an engage employer/purchasers capability  722 . 
       FIG. 8  shows further capabilities  802  including a manage results capability  820 , a communicate value to stakeholders capability  822 , and an execute purchaser specific consultative services capability  824 . 
       FIG. 9  shows further capabilities  902  including a content management capability  920 , a transparency capability  922 , a quality management capability  924 , and a policy oversight capability  926 . 
     The tables provided in the appendix immediately following the abstract, which form part of this disclosure, provide an explanation of the capabilities and corresponding key assessment areas and performance criteria for some of the capabilities within the respective sub-platforms. Each capability may include one or more key assessment areas. Each key assessment area may include one or more additional key assessment areas. In other words, a business capability may include sub-capabilities, and therefore, key assessment areas corresponding to the multiple sub-capabilities. The tables in the appendix show specific criteria used to analyze each capability. 
       FIG. 10  shows a multidimensional health and life sciences industry performance reference set  1000  (“reference set  1000 ”) that provides a capability detail pool from which the system described below may obtain benchmarking tables for a health and life sciences business. The reference set  1000  includes multiple key assessment performance reference tables (“reference tables”), two of which are labeled  1002  and  1004 . Each reference table may provide the benchmarking criteria for a specific capability, such as those noted above with respect to  FIGS. 2-9 . 
     One dimension of each table may establish the ‘Basic’ performance level  140  specifying ‘Basic’ performance assessment criteria, the ‘Competitive’ performance level  142  specifying ‘Competitive’ performance assessment criteria, and the ‘Market Leading’ performance level  144  specifying ‘Market Leading’ performance assessment criteria. Another dimension of each table may specify one or more key assessment areas (KAAs), several of which are labeled  1006 ,  1008 , and  1010 . As noted above, performance criteria, e.g., the PCC  1012 , populates each key assessment performance reference table to provide benchmark criteria for ‘Basic,’ ‘Competitive,’ and ‘Market Leading’ characteristics. 
     The reference set  1000  represents the HPCA model  100 . Consistent with the HPCA model  100 , the reference set  1000  may organize multiple reference tables into a hierarchical structure defining discrete changes in granularity. In one implementation, the hierarchical structure includes reference tables, high-level platforms, platforms, sub-platforms, and models.  FIG. 10  labels three sub-platforms  1014 ,  1016 , and  1018 . The reference set  1000  may further organize the platforms, two of which are labeled  1020  and  1022 . Platforms aggregate into the HPCA model  100  and corresponding reference set  1000 . Additional, different, or fewer levels of granularity may be defined in the HPCA model  100 . 
     The reference set  1000  may dynamically populate the reference tables with the most up-to-date performance criteria, for example upon retrieval and presentation by a business analysis consultant. The performance criteria may be retrieved from a performance capability criteria database or other information source. 
       FIG. 10  also shows an example of a database implementation  1024  of a portion of a reference table. In particular, the database implementation  1024  includes records (e.g., the records  1026 ,  1028 ,  1030 ) that establish each PCC  1012 . In the example shown, each record includes a PCC field  1032 , a category specifier field  1034 , and a KAA specifier field  1036 . Other fields may be provided, such as a reference table assignment field or reference set assignment field. The records categorize each PCC into a specific category (e.g., ‘Basic’), into a specific KAA, and, optionally, into a specific reference table in a specific reference set for any particular HPCA model. 
       FIG. 11  shows a high-performance capability assessment system (“system”)  1100 . The system  1100  includes a processor  1102  and a memory  1104 . Several databases support the operation of the system  1100 , including a performance capability database  1106 , a performance measured database  1108 , a capability detail pool database  1110 , and an assessment results database  1126 . The system  1100  may include a local display  1112  and input/output interfaces  1117  (e.g., including a keyboard, mouse, microphone, speakers, or other device), and, through the communication interface  1114  and networks  1116 , may communicate with remote devices  1118  and remote displays  1120 . The networks  1116  may be any combination of external networks (e.g., the Internet) and internal networks (e.g., corporate LANs). The displays  1112  and  1120  may, for example, present performance capability assessment models  1122  that the system  1100  retrieves from the capability detail pool database  1110  for review, modification, and application by process engineers or other individuals. With regard to local access or access by the remote devices  1118 , the system  1100  may include a login processing program  1124  to authenticate and/or authorize access to the system  1100 . To that end, the login processing program  1124  may include username/password verification, private/public key encryption, or other validation and data protection capabilities. 
     In one implementation, the capability performance database  1106  stores performance criteria. As will be described in more detail below, the system  1100  may populate performance capability assessment models with performance capability criteria suited to any particular platform or sub-platform (e.g., a perform health care management sub-platform  220 ), and business capability at one or more capability levels across one or more key assessment areas. The performance measured database  1108  may store the determined, measured, or otherwise ascertained characteristics, criteria, and other measured data of a particular key assessment area as representative practice data  1148 . The representative practice data  1148  may be obtained through interviews with business consultants and industrial engineers, through online questionnaires, through manual or automated analysis of business data (e.g., year-end operating reports), or in other manners. The capability detail pool database  1110  stores the capability detail pool  1000 , which includes pre-defined performance capability assessment models  1122 . The assessment results database  1126  stores determined capability levels for specific capabilities that have been analyzed. 
     The system  1100  facilitates the review, modification, creation, and application of performance capability assessment models. In that role, performance capability assessment model manipulation logic (“manipulation logic”)  1146  within the system  1100  creates, retrieves, and stores capability assessment data  1128  in the memory  1104 . The manipulation logic  1146  may establish capability assessment data  1128  in the memory  1104 , including a capability assessment data structure  1130  with multiple capability levels (“CL”)  1132  organized along a scale of mastery dimension, multiple key assessment areas (“KAA”)  1134  organized along a key factor dimension, and performance criteria (“PCC”)  1136  that populates the performance capability assessment model  1130 . The manipulation logic  1146  may vary widely in implementation, and, as one example, may include data storage logic  1152  that saves data in memory and user interface logic that accepts capability level specifications, key assessment area specifications, and performance capability criteria inputs to create new performance capability assessment models, to modify existing performance capability assessment models, to delete performance capability assessment models, or to retrieve performance capability assessment models for review. 
     In one implementation, the manipulation logic  1146  establishes the capability assessment data structure  1130  to include a multidimensional health and life sciences industry performance reference set that includes multiple key assessment performance reference tables in which the key assessment performance reference tables include a ‘Basic’ capability performance level, a ‘Competitive’ capability performance level, and a ‘Market Leading’ capability performance level. 
     The capability assessment data  1128  may also include a capability position specifier  1138 . The capability position specifier  1138  may record the capability level along the scale of mastery  146 , as determined for any particular capability. Thus, the system  1100  may store the performance level in the assessment results database  1126  or elsewhere for future retrieval and review. 
     In one implementation, the data population logic  1140  may be a data population program executed by the processor  1102  that populates template performance capability assessment models. For example, the data population logic  1140  may include input logic  1150  that accepts input specifying a capability of interest that indicates a particular performance capability assessment model. The data population logic  1140  may include query logic  1145  that executes database queries and prompts a user for input to obtain the corresponding performance capability criteria for the capability of interest. 
     In another implementation, for example, the query logic  1145  may receive an input specifying a health and life sciences industry area and a health and life sciences industry key assessment area with the health and life sciences industry area for analysis. The query logic  1145  searches the multidimensional health and life sciences industry performance reference set for a matching key assessment performance reference table that matches the health and life sciences industry area and the health and life sciences industry key assessment area, and retrieves the matching key assessment performance reference table. 
     The data population logic  1140  may further include storage logic that adds the retrieved performance capability criteria to the template performance capability assessment model. The data population logic  1140  produces populated performance capability assessment structures  1142  that may be stored in the capability detail pool database  1110 . 
     In addition to the analysis process described above, the system  1100  may provide an automated analysis of representative practice data  1148  that identifies relevant performance capability criteria and determines the position on the scale of mastery  146  of each key assessment area corresponding to the performance capability criteria for the representative practice data  1148 . As one example, the system  1100  may implement capability assessment logic  1144  that includes comparison and/or matching logic that analyzes the representative practice data  1148  with respect to performance capability criteria to locate key assessment areas for which the system  1100  can determine capability levels to obtain a resultant performance level for each key assessment area. 
     Furthermore, the capability assessment logic  1144  may determine an overall position on the scale of mastery  146  as the capability position specifier  1138  for a capability under examination given the knowledge of where the key assessment areas corresponding to the capability under examination fall in each capability level. Thus, for example, the capability assessment logic  1144  may determine an overall capability level for a capability corresponding to the capability level for the majority of the key assessment areas, or it may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery  146  for a capability. As another example, the capability assessment logic  1144  may implement an expert system (e.g., based on a neural network trained on prior determinations) that analyzes the determined characteristics with respect to the performance capability criteria and ascertains where the capability under examination falls along the scale of mastery  146  for each of the key assessment areas, or overall on the scale of mastery. 
       FIG. 12  shows a flow diagram  1200  for creating performance capability assessment models. The performance capability assessment model creator (e.g., the manipulation logic  1146 ) establishes a key factor dimension for the performance capability assessment model ( 1202 ). The performance capability assessment model creator also establishes a capability scale dimension for the performance capability assessment model ( 1204 ). The capability scale dimension may define a scale of increasing organizational capability. For example, the structure creator may create the ‘Basic’ level  140 , the ‘Competitive’ level  142 , and the ‘Market Leading’ level  144 . The performance capability assessment model creator also populates the performance capability assessment model with capability performance criteria ( 1206 ). A capability detail pool  1000  may be formed to hold multiple tailored key assessment performance reference tables ( 1208 ). The performance capability assessment model creator may store the populated assessment structure in the capability detail pool for subsequent retrieval and analysis ( 1210 ). 
       FIG. 13  shows a flow diagram  1300  for retrieving and applying performance capability assessment models. A selection of a capability to be analyzed is obtained ( 1302 ). In one implementation, the system  1100  receives input data that specifies a health and life sciences industry area and a health and life sciences industry key assessment area for analysis. For example, the system  1100  may accept input from a business consultant that specifies a capability for analysis. The system  1100  may query the capability detail pool  1000  for a corresponding performance capability assessment model ( 1304 ). The corresponding performance capability assessment model may be pre-defined in the capability detail pool  1000 , or the data population logic  1140  (or other actor) may populate a performance capability assessment model template that the system  1100  newly creates, or that the system  1100  retrieves from a data store, such as the capability detail pool database  1110 . 
     In another example, the system  1100  searches the multidimensional health and life sciences industry performance reference set in the capability detail pool  1000  for a matching key assessment performance reference table based on the input data that specifies a health and life sciences industry platform and a health and life sciences industry key assessment area. The system  1100  retrieves the matching key assessment performance reference table and initiates analysis of the matching key assessment performance reference table to obtain a resultant performance level for the health and life sciences industry key assessment area. 
     The system  1100  obtains representative practice data  1148  for the capability under examination in the specific business under review ( 1306 ). For example, a business consultant may interview the business to determine how the business currently executes the capability under review. As another example, a representative from the business may complete a questionnaire, submit business data for analysis and parameter extraction, or otherwise provide the characteristics of their current capability execution. As a further example, the system  1100  may retrieve the representative practice data  1148  from a database of previously obtained representative practice data. 
     The system  1100  compares the representative practice data  1148  to the performance criteria in the performance capability assessment model ( 1308 ). For example, a business consultant may use his or her expertise to arrive at a determination of level for the business and the capability under examination ( 1310 ). Alternatively or additionally, the capability assessment logic  1144  may perform an automated analysis of the assessment results data in the assessment results database  1126  and ascertain the performance level on the scale of mastery  146 . The system  1100  may store the assessment results, including the determined performance level, for future reference in the assessment results database  1126  or other location ( 1312 ). 
       FIG. 14  shows a flow diagram  1400  for analyzing representative practice data  1148  to determine a health and life sciences industry and a health and life sciences key assessment area to which the representative practice data applies. The system  1100  receives representative practice data  1148  as input data ( 1402 ). The system  1100  may receive the representative practice data  1148  from a database query performed by the query logic  1145  that the query logic executes periodically, when instructed by an operator, and/or automatically against any number of available database sources that store representative practice data  1148 . The capability assessment logic  1144  analyzes the representative practice data  1148  to identify performance capability criteria in the capability detail pool  1000  that the capability assessment logic  1144  determines relevant to the representative practice data  1148  ( 1404 ). For example, the capability assessment logic  1144  may compare and/or match the content of the representative practice data  1148  with the performance capability criteria using natural language processing (NLP), text string, and/or substring matching, by comparing tags linked to the representative practice data  1148  and that specify that any portion of the representative practice data  1148  is applicable to a specific PCC, by querying for a manual classification of the representative practice data  1148  to a PCC, or other matching technique. The capability assessment logic  1144  may score and/or weight a performance capability criteria and compare the score and/or weight to a user specified relevance threshold to rank the relevance of the performance capability criteria to the representative practice data  1148  ( 1406 ). The user may specify particular terms and/or phrases to search and match between the performance capability criteria and the representative practice data  1148 , in order to score the performance capability criteria. 
     The capability assessment logic  1144  may determine, based on the number of performance capability criteria that meet or exceed the relevance threshold, that the capability assessment logic  1144  has identified a sufficient number of performance capability criteria for a specific key assessment area in order to determine a performance level for the capability as a whole or any key assessment area within the capability ( 1408 ). As one example, where at least 51% of the performance capability criteria for a particular key assessment area meet or exceed the relevance threshold, the capability assessment logic  1144  applies the performance capability criteria to the representative practice data  1148 . In another example, the performance capability criteria for a particular key assessment area may be ranked in importance and/or designated as mandatory in order to assess the key assessment area. In the event the capability assessment logic  1144  identifies the mandatory performance capability criteria for a key assessment area, the capability assessment logic  1144  applies the performance capability criteria to the representative practice data  1148 . 
     The capability assessment logic  1144  may apply the performance capability criteria meeting or exceeding the relevance threshold to the representative practice data  1148  to determine whether any particular PCC is met. Accordingly, as the capability assessment logic  1144  analyzes the PCC, the system  1100  tracks the best fit of the representative practice data  1148  to the PCCs in the key assessment performance reference tables. In other words, the system  1100  determines how the representative practice data  1148  meets (or does not meet) each PCC, thereby gaining insight into whether the representative practice data  1148  is indicative of ‘Basic,’ ‘Competitive,’ or ‘Market Leading’ practices. 
     The system  1100  may also gauge the position on the scale of mastery  146  of each key assessment area corresponding to the performance capability criteria ( 1410 ). The capability assessment logic  1144  may further determine an overall position on the scale of mastery  146  for a capability ( 1412 ). The capability assessment logic  1144  may establish that a desired number and/or designated mandatory performance capability criteria for the key assessment areas have been identified as relevant to a capability and sufficient to determine the position on the scale of mastery  146  for the capability. For example, the capability assessment logic  1144  may determine an overall performance level for the capability based on the performance level determined for the majority of the key assessment areas. The capability assessment logic  1144  may apply a weighted analysis technique to give more emphasis to some key assessment areas than others in determining the overall position on the scale of mastery  146  for the capability. Although selected aspects, features, or components of the implementations are depicted as being stored in computer-readable memories (e.g., as computer-executable instructions or performance capability assessment models), all or part of the systems and structures may be stored on, distributed across, or read from other computer-readable media. The computer-readable media may include, for example, secondary storage devices such as hard disks, floppy disks, and CD-ROMs; a signal, such as a signal received from a network or received at an antenna; or other forms of memory, including ROM or RAM, either currently known or later developed. 
     Various implementations of the system  1100  may include additional or different components. A processor may be implemented as a microprocessor, a microcontroller, a DSP, an application specific integrated circuit (ASIC), discrete logic, or a combination of other types of circuits or logic. Similarly, memories may be DRAM, SRAM, Flash or any other type of memory. The processing capability of the system may be distributed among multiple system components, such as among multiple processors and memories, optionally including multiple distributed processing systems. Parameters, databases, and other data structures may be separately stored and managed, may be incorporated into a single memory or database, may be logically and physically organized in many different ways, and may be implemented in many ways, including data structures such as linked lists, hash tables, or implicit storage mechanisms. Programs may be combined or split among multiple programs, or distributed across several memories and processors. 
     The HPCA  100  model provides unexpectedly good results for a performance capability assessment model, particularly in the health and life sciences industry. In particular, the combinations of key assessment areas and particular assessment criteria of the HPCA model, including the criteria noted in the Appendix of Tables, provide significant advantages over other assessment models. The unexpectedly good results include clearly identifying and delineating from among multiple related complex processes the specific processes to improve, how to improve the process, and identifying concrete and measurable improvement goals. 
     While various embodiments of the invention have been described, it will be apparent to those of ordinary skill in the art that many more embodiments and implementations are possible within the scope of the invention. Accordingly, the invention is not to be restricted except in light of the attached claims and their equivalents. 
     APPENDIX OF TABLES 
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Design Innovative Products 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Design and Incent 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Medical product design at group and 
                 Medical product design at group and 
                 Medical, pharmacy, and wellness product 
               
               
                 subscriber level provides preventive service 
                 subscriber level includes high deductible 
                 design includes dynamic consumer-level 
               
               
                 coverage for minimal out-of-pocket cost 
                 health plan options and provides preventive 
                 benefits and market segmented benefits 
               
               
                 Pharmacy product design channels use of 
                 service coverage 
                 Service design includes strategies to engage 
               
               
                 mail-order and appropriate benefit tiers 
                 Pharmacy product design supports mail- 
                 consumers and measure effectiveness 
               
               
                 When applicable medical and/or pharmacy 
                 order, generic drug incentives (e.g. coupons,  
                 More robust incentives offered: Aligned 
               
               
                 product is supported by a type of health 
                 reward points, co-paying waiving, etc.), and 
                 incentives to medication adherence 
               
               
                 spending account 
                 specialty pharmacy 
                 More robust incentives offered: Consumer 
               
               
                 Traditional Utilization Management is an 
                 Product design includes wellness 
                 selected incentives 
               
               
                 optional feature 
                 components with minimal healthy lifestyle 
                 More robust incentives offered: Increased 
               
               
                 Traditional, episodic Case Management 
                 incentives 
                 incentives for healthy lifestyle 
               
               
                 Disease Management offered for defined list 
                 Product features include access to Affinity 
                 More robust incentives offered: Incentives 
               
               
                 of conditions 
                 networks and product discounts 
                 aligned to disease condition goals 
               
               
                 Inconsistent and fragmented sourcing 
                 Products are supported by tax advantaged 
                 More robust incentives offered: 
               
               
                 strategy 
                 spending accounts, when applicable 
                 Incentive/reward tracker tools 
               
               
                 Product design and pricing driven by Sales 
                 Ease of administration of health spending 
                 Tiered products for wellness based on 
               
               
                 and Marketing team(s) 
                 accounts includes batch cross-over payment 
                 intensity 
               
               
                   
                 Tiered products for Case Management and 
                 Expansion of services offered within Affinity 
               
               
                   
                 Disease Management based on intensity 
                 networks and product discounts (e.g. spa 
               
               
                   
                 Majority of programs and services are 
                 services, chiropractic, acupuncture, etc.) 
               
               
                   
                 insourced providing a more integrated 
                 Option to buy-up concierge services 
               
               
                   
                 experience. Limited outsourced services 
                 Ease of administration of health spending 
               
               
                   
                 with continued fragmentation 
                 accounts includes real time cross-over 
               
               
                   
                 Collaborative product design and pricing 
                 payment 
               
               
                   
                 effort between Sales, Marketing, and Health 
                 Investment and credit products supporting 
               
               
                   
                 Management 
                 spending accounts and high-deductible 
               
               
                   
                   
                 product design 
               
               
                   
                   
                 Minimal outsourcing, when necessary, with 
               
               
                   
                   
                 high degree of integration 
               
               
                   
                   
                 Pricing completed using sophisticated 
               
               
                   
                   
                 models that have been market tested 
               
               
                   
                   
                 Pricing based on lifestyles, accurate staffing 
               
               
                   
                   
                 models, dynamic premium pricing 
               
               
                   
                   
                 Health Management continually introduces 
               
               
                   
                   
                 differentiating product design as part of 
               
               
                   
                   
                 market dynamics and the consultative sales 
               
               
                   
                   
                 process driven by analytics 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Design Services 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Design and Incent 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Focus on episodic and chronic segments of 
                 Focus on healthy, at risk, episodic, and 
                 Focus across entire health care continuum 
               
               
                 health care continuum 
                 chronic segments of health care continuum 
                 Integrated service model, which includes all 
               
               
                 Core traditional Health Management services 
                 Services evolving to integrated health 
                 consumer and provider facing services 
               
               
                 driven by the purchasers (i.e. UM, CM, DM) 
                 advocate model 
                 Personalized assessments and scripting 
               
               
                 Standard services across all market segments 
                 Market segment specific services (e.g. senior 
                 which include consumer engagement 
               
               
                 Static assessments and scripting 
                 segment, etc.) 
                 approaches 
               
               
                 Condition oriented services 
                 Dynamic assessments and scripting 
                 Proactive anticipation of consumer needs 
               
               
                 Metrics tied to operational processes 
                 Whole person oriented services 
                 Actionable high performance metrics tied to 
               
               
                 Segmented service units that support specific 
                 Metrics tied to health and financial outcomes 
                 results with defined accountabilities and 
               
               
                 functions 
                 Coordinated services with some 
                 action plans 
               
               
                   
                 consolidation of service units 
                 Integrated service units 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Design Campaigns 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Design and Incent 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Population based campaigns targeted to 
                 Timely population based campaigns tailored  
                 Personalized campaigns targeted to 
               
               
                 specific conditions or disease states 
                 to specific segments 
                 individual opportunities and preferences 
               
               
                 Limited metrics defined to measure impact 
                 Purchaser driven campaign identification and 
                 during optimal impact period 
               
               
                 and value of campaign 
                 design 
                 Segment specific outreach channels (e.g. 
               
               
                 Campaign channels limited to mail or phone  
                 Specific metrics defined to measure impact 
                 satellite radio, magazine, online TV, etc.) 
               
               
                 Condition based content 
                 and value of campaigns 
                 Personalized and consumer preferred 
               
               
                   
                 Addition of web-based channels (e.g. portal, 
                 channels for outreach 
               
               
                   
                 email, etc.) for campaign outreach and 
                 Specific metrics defined to measure impact 
               
               
                   
                 content distribution 
                 and value of campaigns 
               
               
                   
                 Use of a campaign management solution 
                 Integrated campaign management solution 
               
               
                   
                 Prevention, condition, and segment based 
                 for enterprise 
               
               
                   
                 content 
                 Personalized, prevention, condition, and 
               
               
                   
                   
                 segment based content 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Project Population Health and Wealth Indicators 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Segment and Target 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Identify consumers based on defined criteria, 
                 Leverage multiple traditional data sources 
                 Utilize data from varying data sources to 
               
               
                 historical data, and available reports 
                 (e.g. claims, health assessment, etc.) and 
                 segment consumer population and design and 
               
               
                   
                 basic analytics to segment consumer 
                 execute trajectory predictors 
               
               
                   
                 population 
                 Traditional - claims, health assessment, labs, 
               
               
                   
                 Integrates data sources into single, unified 
                 pharmacy, etc. 
               
               
                   
                 view across Health Management functions 
                 Non-traditional - behavioral marketing data, 
               
               
                   
                 Population based financial and clinical 
                 3rd party consumer data, etc. 
               
               
                   
                 impacts are incorporated into segmentation 
                 Integrates data sources into single, unified 
               
               
                   
                 and algorithms 
                 view across the enterprise (e.g. customer 
               
               
                   
                 Dedicated team that systematically reviews 
                 service, provider relations, Health 
               
               
                   
                 segmentation and algorithms to identify and 
                 Management, etc.) 
               
               
                   
                 implement improvements 
                 Comprehensive consumer insight capabilities 
               
               
                   
                   
                 to identify consumer during their impact 
               
               
                   
                   
                 period 
               
               
                   
                   
                 Consumer level financial and clinical impact 
               
               
                   
                   
                 analysis 
               
               
                   
                   
                 Integrated informatics capabilities across the 
               
               
                   
                   
                 enterprise (e.g. actuarial, marketing, clinical, 
               
               
                   
                   
                 etc.) 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 5 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Identify Individual Intervention Opportunities 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Segment and Target 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Interventions identified based on program 
                 Intervention opportunities identified using 
                 Intervention opportunities identified based on 
               
               
                 definition and clinical guidelines (e.g. risk 
                 evidence-based medical (EBM) guidelines 
                 consumer&#39;s individual clinical, financial, and 
               
               
                 level, diagnoses, procedures, etc.) 
                 Prioritized intervention opportunities based 
                 lifestyle data 
               
               
                 Individual clinical judgment determines 
                 on defined clinical pathways which 
                 Systematically prioritized health and wealth 
               
               
                 priority of interventions and consumers for 
                 incorporate co-morbidities 
                 intervention opportunities based on predicted 
               
               
                 outreach 
                 Adherence to standardized quality measures 
                 level of clinical and financial impact for the 
               
               
                   
                 for the highest level of accreditation (e.g. 
                 specific consumer 
               
               
                   
                 URAC/NCQA) 
                 Real time active monitoring and execution 
               
               
                   
                 Population based financial and clinical 
                 Actual consumer level financial and clinical 
               
               
                   
                 impacts are incorporated into opportunity 
                 outcomes are utilized for ongoing 
               
               
                   
                 identification 
                 improvements to opportunity identification 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 6 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Perform Proactive Outreach 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Reach and Engage 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Mail and telephone outreach channels 
                 Addition of web-based channels (e.g. portal, 
                 Segment specific outreach channels (e.g. 
               
               
                 Static assessments and scripting 
                 email, chat, etc.) 
                 satellite radio, magazine, online TV, etc.) 
               
               
                 Limited measurement of impact and value of 
                 Use of customer service/provider service as a 
                 Personalized and consumer preferred 
               
               
                 campaigns 
                 channel for outreach 
                 channels for outreach 
               
               
                 Use of high-cost, high-skilled resources for 
                 Dynamic assessments and scripting 
                 Personalized, intervention-specific 
               
               
                 outreach 
                 Channel consumer to network providers and 
                 assessments and scripting 
               
               
                   
                 facilities 
                 Offer provider cost and quality data to 
               
               
                   
                 Measurement and analysis of campaign 
                 empower and influence consumer  
               
               
                   
                 outcome 
                 decision-making 
               
               
                   
                 Use of non-clinical resources for outreach as 
                 Active discussion with providers regarding 
               
               
                   
                 appropriate 
                 comparative utilization data (e.g. cost and 
               
               
                   
                   
                 quality) to improve outcomes 
               
               
                   
                   
                 Use of measurement and analysis of 
               
               
                   
                   
                 campaign outcomes to refine future 
               
               
                   
                   
                 campaigns 
               
               
                   
                   
                 Use of law cost, high yield, non-clinical 
               
               
                   
                   
                 resources for outreach as appropriate 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 7 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Coordinate Care 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Reach and Engage 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Execute authorization review: Authorization 
                 Execute authorization review: Shift to 
                 Execute authorization review: Focused 
               
               
                 policies are broadly applied 
                 automated notifications 
                 authorization on high impact opportunities 
               
               
                 Execute authorization review: Manual entry 
                 Execute authorization review: Use of IVR, 
                 Execute authorization review: Use of 
               
               
                 of fax and phone data 
                 web and EDI to automate authorization data 
                 automated notifications to trigger programs 
               
               
                 Execute authorization review: Multiple 
                 entry 
                 and services 
               
               
                 clinical criteria sets applied inconsistently  
                 Execute authorization review: Consistent 
                 Execute authorization review: Use of 
               
               
                 (e.g. Interqual, Milliman, etc.) 
                 clinical criteria set 
                 clinical workflow tools and rules engine to 
               
               
                 Execute authorization review: Use of a non- 
                 Execute authorization review: Leveraged 
                 support automated adjudication and 
               
               
                 leveraged clinical/non-clinical resource 
                 model with mix of clinical and non-clinical 
                 distribution of authorizations/notifications 
               
               
                 model for non-clinical transactions 
                 resources for non-clinical transactions 
                 Execute authorization review: Non-clinical 
               
               
                 Perform inpatient concurrent review and 
                 Perform inpatient concurrent review and 
                 transactions supported by low cost, high 
               
               
                 discharge planning: Onsite, intensive 
                 discharge planning: Primarily telephonic 
                 yield, non-clinical resources as appropriate 
               
               
                 concurrent review with duplicative steps (e.g. 
                 concurrent review model 
                 Perform inpatient concurrent review and 
               
               
                 manual, paper-based charting that is then 
                 Perform inpatient concurrent review and 
                 discharge planning: Shift to technology- 
               
               
                 typed into a system) 
                 discharge planning: Discharge planning is 
                 based concurrent review transactions 
               
               
                 Perform inpatient concurrent review and 
                 proactive with limited integration with other  
                 Perform inpatient concurrent review and 
               
               
                 discharge planning: Discharge planning is 
                 services 
                 discharge planning: Focused telephonic 
               
               
                 manual, reactionary, and silo&#39;d 
                 Manage appeals and grievances: 
                 concurrent review model (e.g. LOS outliers, 
               
               
                 Manage appeals and grievances: Simple 
                 Coordinated processes with customer 
                 facility outliers, etc.) with onsite for high 
               
               
                 processes and systems (e.g. Access 
                 service, provider service and claims 
                 volume facilities and specific cases 
               
               
                 databases) to support resolution (typically 
                 processing; multiple systems to support 
                 Perform inpatient concurrent review and 
               
               
                 fragmented with multiple handoffs) 
                 appeals and grievances which are typically 
                 discharge planning: Discharge planning is 
               
               
                 Evaluate opportunities for programs/services: 
                 not integrated 
                 proactive, targeted, integrated with other 
               
               
                 Opportunities identified based on chronic or 
                 Evaluate opportunities for programs/services: 
                 services, and supported by automated tools 
               
               
                 episodic condition 
                 Intervention opportunities identified using 
                 Manage appeals and grievances: Integrated 
               
               
                 Evaluate opportunities for programs/services: 
                 evidence-based medical (EBM) guidelines 
                 processes and systems for coordination with 
               
               
                 Opportunities driven by health plan business 
                 Evaluate opportunities for programs/services: 
                 customer service, provider service, and 
               
               
                 objectives 
                 Prioritized intervention opportunities based 
                 claims processing 
               
               
                 Develop care plan - Care plan is created 
                 on defined clinical pathways which 
                 Evaluate opportunities for programs/services: 
               
               
                 based on chronic or episodic condition 
                 incorporate co-morbidities 
                 Intervention opportunities identified based on 
               
               
                 Develop care plan - Care plan is driven by 
                 Evaluate opportunities for programs/services: 
                 consumer&#39;s individual clinical, financial and 
               
               
                 health plan business objectives 
                 Obtain consumer understanding and consent 
                 lifestyle data 
               
               
                 Coordinate and manage care plan - Simple 
                 regarding intervention opportunities driven 
                 Evaluate opportunities for programs/services: 
               
               
                 processes and systems to support care plans 
                 by EBM guidelines 
                 Systematically prioritized health and wealth 
               
               
                 which are stand-alone and segregated 
                 Develop care plan - Care plan is created 
                 intervention opportunities based on predicted 
               
               
                 Coordinate and manage care plan - 
                 based on intervention opportunities and 
                 level of clinical and financial impact for the 
               
               
                 Engagement, disengagement, graduation or 
                 clinical guidelines 
                 specific consumer 
               
               
                 step-down criteria for consumers based 
                 Develop care plan - Obtain consumer 
                 Evaluate opportunities for programs/services: 
               
               
                 primarily on clinical judgment 
                 understanding and consent regarding care 
                 Collaboration with consumer to personalize 
               
               
                 Coordinate and manage care plan - Clinician 
                 plan driven by EBM guidelines 
                 intervention opportunities 
               
               
                 access to providers to collect information and 
                 Coordinate and manage care plan - 
                 Develop care plan - Individualized, iterative 
               
               
                 vendors/partners to provide services 
                 Coordinated processes within Health 
                 care plan is created based on prioritized 
               
               
                 Coordinate and manage care plan - Services 
                 Management services; shared access to 
                 health and wealth intervention opportunities 
               
               
                 conducted primarily via telephone and mail 
                 multiple systems to support care plan 
                 Develop care plan - Collaboration with 
               
               
                   
                 Coordinate and manage care plan  
                 consumer to personalize care plan goals and 
               
               
                   
                 Standardized criteria used to determine 
                 activities 
               
               
                   
                 engagement, disengagement, graduation or 
                 Coordinate and manage care plan - Integrated 
               
               
                   
                 step-down criteria 
                 processes within Health Management 
               
               
                   
                 Coordinate and manage care plan - Integrated 
                 services; access to integrated system to 
               
               
                   
                 care plan that defines and tracks goals and 
                 support care plan which includes both health 
               
               
                   
                 action items 
                 and wealth intervention opportunities 
               
               
                   
                 Coordinate and manage care plan - Clinician 
                 Coordinate and manage care plan - 
               
               
                   
                 access to subject matter advisors, providers, 
                 Reputable, research based theories and 
               
               
                   
                 and vendors/partners to provide support 
                 models (TTM, PAM, motivational 
               
               
                   
                 according to consumer need 
                 interviewing, etc.) are used as a foundation to 
               
               
                   
                 Coordinate and manage care plan - Provide 
                 determine engagement, disengagement, 
               
               
                   
                 interactive tools and content for consumer 
                 graduation and step-down criteria 
               
               
                   
                 self-management 
                 Coordinate and manage care plan - 
               
               
                   
                 Coordinate and manage care plan - Ability to 
                 Interactive care plan with ability to track 
               
               
                   
                 distribute care plan to consumer and provider 
                 goals and action items accessible via multiple 
               
               
                   
                 Coordinate and manage care plan - Addition 
                 channels with customized views for 
               
               
                   
                 of web-based channels (e.g. portal, email, 
                 consumer and approved care team (e.g. Care 
               
               
                   
                 etc.) 
                 Navigator, provider, designated caregiver, 
               
               
                   
                   
                 etc.) 
               
               
                   
                   
                 Coordinate and manage care plan - Online 
               
               
                   
                   
                 Personal Health Record (PHR) maintained 
               
               
                   
                   
                 utilizing multiple data sources (e.g. claims, 
               
               
                   
                   
                 pharmacy, biometric data, lab data, etc.) and 
               
               
                   
                   
                 integrated with care plan 
               
               
                   
                   
                 Coordinate and manage care plan - Single 
               
               
                   
                   
                 point of contact (e.g. primary care navigator) 
               
               
                   
                   
                 that coordinates with interdisciplinary team, 
               
               
                   
                   
                 enterprise functions (customer service, 
               
               
                   
                   
                 provider service, etc.) providers, and 
               
               
                   
                   
                 vendors/partners to provide support activities 
               
               
                   
                   
                 Coordinate and manage care plan - Access to 
               
               
                   
                   
                 robust, integrated coaching tools that include 
               
               
                   
                   
                 trending capabilities, goal tracking and 
               
               
                   
                   
                 modeling 
               
               
                   
                   
                 Coordinate and manage care plan - Multi- 
               
               
                   
                   
                 channel, personalized, interactive coaching 
               
               
                   
                   
                 customized to consumer and provider needs, 
               
               
                   
                   
                 objectives and preferences with broader 
               
               
                   
                   
                 access to person to person coaching, support 
               
               
                   
                   
                 groups, online chat, etc. 
               
               
                   
                   
                 Coordinate and manage care plan - 
               
               
                   
                   
                 Collaboration with consumer to personalize 
               
               
                   
                   
                 care plan goals and activities 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 8 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Promote Optimal Lifestyle 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Reach and Engage 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Lifestyle promotion limited to consumer 
                 Typical wellness programs offered include  
                 Optimal lifestyle programs evolving to 
               
               
                 health education (usually CM/DM nurses) 
                 tobacco cessation, weight management, and 
                 include sleep, nutrition, exercise, and wealth 
               
               
                 Engagement, disengagement, graduation or 
                 stress management 
                 management aligned with personalized 
               
               
                 step-down criteria for consumers based 
                 Tiered program options include buy-up to 
                 reward programs and incentives 
               
               
                 primarily on clinical judgment 
                 coaching performed by licensed or certified 
                 Multi-channel, personalized, interactive 
               
               
                 Interventions with consumers based 
                 professionals (i.e. registered dietician, 
                 coaching customized to consumer and 
               
               
                 primarily on episodic events or chronic 
                 exercise physiologist, certified wellness 
                 provider needs, objectives and preferences 
               
               
                 condition 
                 coach, etc.) 
                 with broader access to person to person 
               
               
                 Optional general health assessment is used to  
                 Basic behavior modification methods are 
                 coaching, support groups, online chat 
               
               
                 provide consumer&#39;s individual report and 
                 used to determine engagement, 
                 Reputable, research based theories and 
               
               
                 relevant content 
                 disengagement, graduation and step-down 
                 models (TTM, PAM, motivational 
               
               
                   
                 criteria; includes creation of personalized 
                 interviewing, etc.) are used as a foundation to 
               
               
                   
                 action plan and coordinated goal setting 
                 determine engagement, disengagement, 
               
               
                   
                 Interventions with consumers based on 
                 graduation and step-down criteria 
               
               
                   
                 triggers from general health assessments in 
                 Behavior modification skills and approach 
               
               
                   
                 addition to chronic conditions or episodic 
                 integrate into all Health Management 
               
               
                   
                 events 
                 services 
               
               
                   
                 Provide interactive tools and content for 
                 Interventions with consumers based on 
               
               
                   
                 consumer self-management (sustainability) 
                 triggers from all available data sources (e.g. 
               
               
                   
                 Offer optional purchaser sponsored health 
                 biometrics, lab data, health fair data, kiosk 
               
               
                   
                 and wellness fairs 
                 devices, genomics, etc. 
               
               
                   
                   
                 Pursue pilots/opportunities to leverage 
               
               
                   
                   
                 relationships, with other vendors/partners 
               
               
                   
                   
                 (e.g. pharmaceutical companies, PBM, etc.) 
               
               
                   
                   
                 Access to robust, integrated coaching tools 
               
               
                   
                   
                 that include trending capabilities, goal 
               
               
                   
                   
                 tracking and modeling 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 9 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Engage Provider 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Collaborate and Support 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Collaboration on Health Management 
                 Collaboration on Health Management 
                 Treatment Opportunities and Care Plans - 
               
               
                 Program Design - Medical Directors meet 
                 Program Design - Physicians are paid to 
                 Near real time, online notification of 
               
               
                 with Professional Organizations to promote 
                 participate in facilitated design sessions 
                 treatment opportunities (care gaps) and 
               
               
                 programs 
                 Treatment Opportunities - Notify provider, in 
                 health risks of patients. Leverage provider 
               
               
                 Treatment Opportunities - Disease 
                 timely manner, of treatment opportunities 
                 connectivity channels 
               
               
                 management programs notify physician of 
                 (i.e., care gaps) and health risks of patients  
                 Treatment Opportunities and Care Plans - 
               
               
                 patient participation in program 
                 Treatment Opportunities - Paper based and 
                 Provide access to web based care plan tool 
               
               
                 Treatment Opportunities quarterly 
                 usually monthly or quarterly 
                 and reward physician for creation of care 
               
               
                 Provider Payment Strategies - Limited to 
                 Provider Payment Strategies - Provider 
                 plan that can be shared with broader care 
               
               
                 provider contracts focused on fee schedules 
                 payment strategies aligned with health 
                 team 
               
               
                 Decision Support - Paper based decision 
                 outcomes, quality of care and interaction 
                 Provider Payment Strategies - Providers are 
               
               
                 support - mostly in the form of newsletters 
                 with health management programs and tools. 
                 incented to proactively manage their patient 
               
               
                 and policy updates 
                 Leverage this data to align fee schedules and 
                 population (not just reactive medicine) 
               
               
                   
                 contracts 
                 including payments for: (e.g. patient 
               
               
                   
                 Provider Connectivity - Support timely, 
                 centered medical home concept) 
               
               
                   
                 online interaction 
                 Provider Payment Strategies - Work 
               
               
                   
                 Provider Connectivity - Prior Authorizations 
                 required to proactively review aggregate 
               
               
                   
                 Provider Connectivity - Referral network 
                 population and individual information to 
               
               
                   
                 (specialist referrals) 
                 identify risks 
               
               
                   
                 Provider Connectivity - Formulary 
                 Provider Payment Strategies - Work that 
               
               
                   
                 information - cost, alternatives, drug-to-drug 
                 falls outside of the face-to-face visit to 
               
               
                   
                 interactions 
                 proactively care for patients 
               
               
                   
                 Provider Connectivity - Real time eligibility 
                 Provider Payment Strategies - Payment 
               
               
                   
                 Provider Connectivity - Real time claim 
                 for remote monitoring of clinical data using 
               
               
                   
                 adjudication to obtain near real time data for 
                 technology 
               
               
                   
                 Care Management 
                 Provider Payment Strategies - Online reports 
               
               
                   
                 Decision Support - Support clinical decision 
                 to provider on status of incentive rewards 
               
               
                   
                 making with: 
                 Provider Connectivity - Support channels 
               
               
                   
                 Access to evidence based guidelines 
                 that provide near-real time patient 
               
               
                   
                 Patient-specific administrative 
                 information that is both portable and 
               
               
                   
                 information (e.g., benefits information) 
                 accessible to enable the provider (e.g. 
               
               
                   
                 Drug interaction and allergy warnings 
                 Physicians, ER, retail clinics) to make 
               
               
                   
                 Identification of medication 
                 decisions during a patient encounter 
               
               
                   
                 contraindications 
                 Provider Connectivity - Support timely, 
               
               
                   
                 Provider Value Reports - Physicians receive 
                 online interaction for: 
               
               
                   
                 yearly paper based reports that communicate: 
                 Provider Connectivity - Personal health 
               
               
                   
                 Provider Value Reports - Annual report 
                 Record information - with messages related 
               
               
                   
                 on number of patients that have participated 
                 to care gaps and risks identified 
               
               
                   
                 in Health Management Programs 
                 Provider Connectivity - Cost Calculator - 
               
               
                   
                 Provider Value Reports - Comparison of 
                 estimate physician payment and member out- 
               
               
                   
                 utilization trends - from past years and 
                 of-pocket expense 
               
               
                   
                 compared to peers 
                 Decision Support - Support clinical decision 
               
               
                   
                 Provider Value Reports - Usage of 
                 making with: 
               
               
                   
                 decision support tools 
                 Patient-specific clinical information 
               
               
                   
                   
                 Cost-effective treatment options 
               
               
                   
                   
                 Identification of treatment adherence 
               
               
                   
                   
                 issues 
               
               
                   
                   
                 Provider Value Reports - Physicians receive 
               
               
                   
                   
                 value reports, online, quarterly - or on 
               
               
                   
                   
                 demand 
               
               
                   
                   
                 Provider Value Reports - Enhancements to 
               
               
                   
                   
                 quarterly reports that communicate: 
               
               
                   
                   
                 Provider Value Reports - Health outcomes 
               
               
                   
                   
                 achieved through Health Management 
               
               
                   
                   
                 programs - for physician population 
               
               
                   
                   
                 Provider Value Reports - Percentage 
               
               
                   
                   
                 achievement of goals to achieve reward 
               
               
                   
                   
                 dollars 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 10 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Engage Purchaser/Employer 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Collaborate and Support 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Value Reporting - Paper based reports - 
                 Value Reporting - Standard value-based 
                 Value Reporting - Offer online reporting to 
               
               
                 usually once a year during contract renewal 
                 reports available on purchaser web site - 
                 all accounts - regardless of size 
               
               
                 Value Reporting - Standard reporting is only 
                 target is large accounts 
                 Value Reporting - Drill-down capability on 
               
               
                 available to mid to large sized accounts 
                 Value Reporting - Automated report process, 
                 online reports to do ad hoc analysis. 
               
               
                 Value Reporting - Operational/process 
                 limited or no manual intervention 
                 Parameter Driven Reports and Interactive 
               
               
                 measures are reported (e.g. number of 
                 Value Reporting - Value clearly articulated - 
                 Reports that are created on demand 
               
               
                 participants reached) - limited ROI reporting 
                 clinical outcomes, financial outcomes and 
                 Consultative Services - Automated purchaser 
               
               
                 Value Reporting - Manually intensive 
                 operational efficiencies 
                 opportunity analysis with rules that create 
               
               
                 process to analyze data and limited 
                 Consultative Services - Conduct account- 
                 recommendations for programs, metrics and 
               
               
                 recommendations based on member 
                 specific assessments to help clients improve 
                 targets 
               
               
                 experience 
                 their business to obtain a better ROI from 
                 Incentive Programs - Create employer 
               
               
                 Value Reporting - Medical Director goes 
                 their healthcare investments - target “A” 
                 incentives for encouraging healthy behaviors 
               
               
                 with Sales Rep to represent Health 
                 Accounts 
                 within employee population. Annually, 
               
               
                 Management 
                 Consultative Services - Establish baselines, 
                 modify contracts/premiums based on percent 
               
               
                 Consultative Services - Limited collaboration 
                 identify employer specific opportunities to 
                 of employee population that achieved agreed 
               
               
                 between Sales force and Care Management 
                 manage health, make recommendations for 
                 upon goals 
               
               
                 Worksite Programs - Small number of health 
                 programs, set annual goals/targets 
                 Worksite Programs - Collaborate with large 
               
               
                 fairs conducted at time of open enrollment at 
                 Consultative Services - Manual analysis 
                 employers to set up onsite health clinics with 
               
               
                 large employers 
                 required 
                 broad spectrum of non-urgent services (e.g., 
               
               
                   
                 Consultative Services - Collaborate with the 
                 symptom advice/treatment, condition 
               
               
                   
                 Account Manager to articulate care 
                 coaching, etc.) 
               
               
                   
                 management solutions 
                 Worksite Programs - Create new innovative 
               
               
                   
                 Incentive Programs - Collaborate with 
                 employee health management services (e.g., 
               
               
                   
                 employers to offer employer-funded 
                 health concierge services, health/wealth 
               
               
                   
                 incentives to employees 
                 retirement planning) 
               
               
                   
                 Incentive Programs - Report on employee 
                   
               
               
                   
                 uptake of incentive programs and impact of 
                   
               
               
                   
                 program on health outcomes 
                   
               
               
                   
                 Worksite Programs - Collaborate with 
                   
               
               
                   
                 Purchasers to support health fairs, lunch and 
                   
               
               
                   
                 learns, and other wellness programs. 
                   
               
               
                   
                 Prioritize accounts to optimize use of limited 
                   
               
               
                   
                 resources 
                   
               
               
                   
                 Worksite Programs - Develop Employer 
                   
               
               
                   
                 “tool-kits” with example programs and 
                   
               
               
                   
                 materials to initiate employer wellness 
                   
               
               
                   
                 initiatives 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 11 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Manage Results 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Evaluate and Improve 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Enterprise-wide measurement methodology 
                 Engagement of stakeholders in determining 
                 Collaboration with stakeholders to determine 
               
               
                 defined by health plan 
                 measurement methodology 
                 measurement methodology leveraging 
               
               
                 Paper-based report distribution 
                 Electronic report distribution 
                 industry standards 
               
               
                 Manual reporting for regulatory compliance, 
                 Annual reporting on outcomes and ROI for 
                 Executive dashboard generated to understand 
               
               
                 contractual obligations and operational 
                 operational management, provider 
                 high-level cost and utilization trends across 
               
               
                 management 
                 performance and purchaser value reporting 
                 the enterprise 
               
               
                   
                 Vendor Data is included in reports 
                 Dynamic, interactive, individualized reports 
               
               
                   
                 Ability to perform metrics evaluation 
                 with drill-down capabilities and 
               
               
                   
                 compared to expected thresholds 
                 identification of actionable items 
               
               
                   
                 Dedicated team to manage standard reports 
                 On-demand reporting on outcomes and ROI 
               
               
                   
                 and ad hoc reports for root cause analysis 
                 for operational management, provider 
               
               
                   
                 Leverage root cause analysis for internal 
                 performance and purchaser value reporting 
               
               
                   
                 continuous improvement 
                 Seamless, systematic incorporation of vendor 
               
               
                   
                   
                 data 
               
               
                   
                   
                 Executive accountability and ownership for 
               
               
                   
                   
                 enterprise-wide healthcare informatics 
               
               
                   
                   
                 Leverage real time predictive analysis for 
               
               
                   
                   
                 trending and alerts with defined actionable 
               
               
                   
                   
                 items 
               
               
                   
                   
                 Leverage results management capabilities for 
               
               
                   
                   
                 stakeholder continuous improvement 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 12 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Communicate Value to Stakeholders 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Evaluate and Improve 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Paper-based explanation of benefits (EOB) 
                 Paper-based personalized health statements 
                 Electronic, dynamic, integrated personal 
               
               
                   
                   
                 health statements with actionable targeted 
               
               
                   
                   
                 messaging 
               
               
                   
                   
                 Interactive modeling 
               
               
                   
                   
                 Personalized ROI reports with ability to do 
               
               
                   
                   
                 interactive modeling (i.e. ability for 
               
               
                   
                   
                 consumers to adapt/change inputs) 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 13 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Provide Account Specific Consultative Services 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Evaluate and Improve 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Utilize reports to monitor utilization and 
                 Utilize reports to monitor utilization, 
                 Comprehensive, interactive reports with in- 
               
               
                 program efficiency to determine if services 
                 program efficiency, and value to determine if 
                 depth analysis and interpretation including 
               
               
                 need to be added or modified 
                 services need to be added or modified 
                 productivity, absenteeism, and presenteeism 
               
               
                 Basic set of reports handed off to account 
                 Basic set of reports provided to account 
                 Account representatives have the training 
               
               
                 representative with limited analysis 
                 representative with analysis and 
                 and tools to perform interactive, dynamic 
               
               
                 Ad hoc purchaser data generated upon 
                 interpretation 
                 opportunity assessment and program 
               
               
                 purchaser request, limited by health plan 
                 Customer understanding and relationship 
                 planning 
               
               
                 capability 
                 development is data driven and fact-based 
                 Health Management advisors involved in 
               
               
                 Customer understanding and relationship 
                 utilizing internal and external sources 
                 consultative sales process 
               
               
                 development is an “art” versus fact and data  
                 Defined delivery approach and processes 
                 Customer understanding and relationship 
               
               
                 driven 
                 leveraging Health Management advisors on 
                 development is trust-based, interactive, and 
               
               
                 Basic delivery approach and processes driven  
                 an as needed basis 
                 reflects the depth of knowledge on the 
               
               
                 by reaction to purchaser requests (typically 
                   
                 customer obtained from personal 
               
               
                 inconsistent, segmented and silo&#39;d) 
                   
                 interactions, understanding of the customer&#39;s 
               
               
                   
                   
                 strategic objectives and relevant data 
               
               
                   
                   
                 Collaborative approach driven by insight to 
               
               
                   
                   
                 proactively identify customer needs to 
               
               
                   
                   
                 achieve strategic objectives 
               
               
                   
               
             
          
         
       
     
     
       
         
               
             
               
               
             
               
               
               
             
           
               
                 TABLE 14 
               
             
             
               
                   
               
               
                 Capability Assessment Model 
               
               
                 Payer - Coordinate Healthcare Services 
               
               
                 Provide Decision Support 
               
             
          
           
               
                 Sub-Platform: Perform Health Management 
                 Capability: Research and Engage 
               
             
          
           
               
                 Basic 
                 Competitive 
                 Market Leading 
               
               
                   
               
               
                 Focused on treatment option decisions for 
                 Focused on health decisions for preference 
                 Offer full spectrum of health and wealth 
               
               
                 chronic or episodic conditions to support 
                 sensitive conditions based on health plan 
                 decision support based on consumer needs 
               
               
                 CM/DM 
                 ROI (e.g. pain management, surgery, 
                 (e.g. provider selection, medication therapy, 
               
               
                 Guidance on health care options provided 
                 fertility, oncology decisions, etc.) 
                 palliative care, medical tourism, etc.) 
               
               
                 according to health plan guidelines and 
                 Proactive identification of consumers 
                 Proactive identification of consumers during 
               
               
                 policy 
                 through “trigger list” of diagnoses and 
                 optimal impact period through predictive 
               
               
                 Access to static information based on 
                 procedures 
                 analysis 
               
               
                 medical policy 
                 Access to static information based on 
                 Multi-channel access to interactive, 
               
               
                   
                 evidence-based medical guidelines 
                 customized content, messaging and tools 
               
               
                   
                 Coaching consumer to have appropriate 
                 (e.g. cost calculators, decisions trees, etc.) 
               
               
                   
                 dialog with provider (e.g. developing list of 
                 regarding health and wealth options, 
               
               
                   
                 questions, creating checklist, etc.) 
                 including access to interactive personal 
               
               
                   
                 Access to clinical decision support content, 
                 health and wealth advisor services 
               
               
                   
                 clinical care paths, basic cost and quality data  
                 Support consumer dialog with provider (e.g. 
               
               
                   
                 (e.g. Subimo, CMS, etc.) 
                 coaching, joint conversation, etc.) 
               
               
                   
                 Access to subject matter advisors to provide 
                 Ability for consumer to access health plan 
               
               
                   
                 decision support according to consumer need 
                 and consumer rating information on 
               
               
                   
                   
                 providers (e.g. quality, cost, consumer 
               
               
                   
                   
                 satisfaction data, etc.) 
               
               
                   
                   
                 Access to interdisciplinary team to provide 
               
               
                   
                   
                 decision support according to consumer need