Symmetry® Pharmacy Risk Groups®

Understand and measure member health

Symmetry Pharmacy Risk Groups (PRG®) is pharmacy-based health risk assessment software that uses prescription data and proprietary classification systems to help organizations better understand and measure member health risk.

PRG provides risk measures for every individual in a managed population, and helps users make timely predictions regarding those members with highest risk.

Measure member health risk
  • Calculate relative health risk scores for individuals
  • Develop markers for pharmaceutical treatments
  • Determine the key factors driving relative risk
  • Better predict future health care costs and pharmaceutical use

Pharmacy-based health risk assessment system

Compared to medical claims, pharmacy claims data is available to managed care organizations faster, typically within two weeks of the prescription fill date. PRG allows for assessment of risk without access to past medical utilization data. Using prescription data and proprietary classification systems to create markers of health risk that may indicate a patient's disease prevalence, severity and comorbidities, health care analysts and actuaries can more accurately predict future health care costs and risk with PRG.

PRG creates markers of risk in the areas of disease prevalence, severity and comorbidities, combines these markers with others that describe an individual's age and gender. It then assigns appropriate weight to each to provide a measure of each individual’s potential need for future health care services.

Medical and care management applications

In addition to providing risk assessments with pharmacy data for every individual in a population, PRG helps users make timely predictions regarding those members highest in risk, supporting:

  • Predictive Modeling. This identifies members who are at risk for catastrophic utilization.
  • Disease and Care Management. This stratifies patients within a particular disease in order to promote timely and appropriate interventions.
  • Health Risk Assessment. This assesses health risk for members without past medical utilization as well as members more recently enrolled with a health plan.
  • Care Management. This includes planning and resource allocation driven by the clinical outputs from PRG.

Financial/Actuarial applications

PRG supports actuaries and underwriters in setting appropriate premium rates and in more accurately matching premium revenue with expected health care expenses. This support includes:

  • Timeliness of Rate Setting. Achieve a quick completion rate for pharmacy claims and execute more timely risk assessment and underwriting.
  • Rating New Groups. Access the pharmacy claims data that may be more readily available for new accounts being considered for underwriting — and provide valuable information for the underwriting of new cases
  • Describing Disease Prevalence and Comorbidities. Take advantage of PRG® outputs that summarize profiles of underlying diseases and conditions based on pharmacy treatment patterns
  • IBNR Calculations and Reserve Allocation. Leverage claims completion and prediction timeliness performance to incorporate PRG results into methodologies used to compute IBNR adjustments and reserve allocation

PRG is part of the Symmetry Suite of products supporting provider measurement, population and individual health care measurement, and clinical and financial trend analysis. The suite includes:

  • Episode Treatment Groups®. These groups are the market’s leading episode groupers.
  • Episode Risk Groups®. These groups predict current and future health care usage for individuals and groups.
  • PCQ Connect®. This provides comparisons of physician peer groups and performance.
  • Procedure Episode Groups®. These groups categorize surgical procedures to form consistent episodes of care for analysis of clinical specialists.
  • EBM Connect®. This measures patient and provider compliance to evidence-based guidelines.