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Robert Chen

MBR-30911 · 58y M · Self-funded — Acme Manufacturing PPO

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Demographics

Member ID
MBR-30911
DOB
1967-09-21 (58y)
Sex
Male
Health Plan
Self-funded — Acme Manufacturing PPO
Eligibility
Active · since 2022-01-01
Line of Business
Medicare Advantage · HMO
PCP
Dr. Sara Nguyen
Phone
(415) 555-0188
Address
88 Folsom St, San Francisco CA 94105
Risk Score
74%
Tier 4 of 4
RAF (current)
1.62
Projected 1.78
Predicted Admit
74%
30-day inpatient
Annual Spend
$391K
YTD $188K

Utilization Summary

trailing 12 months
ER Visits
6
Admissions
3
Readmissions
1
Specialists Seen
3
Total Medical $
$127K
PMPM
$4,017
48 mo enrolled

Pharmacy Summary

active fills, last 90 days
Active Medications
6
Avg Adherence (PDC)
84%
Specialty Drugs
1
Savings Opportunities
$25K

Risk Score Trajectory

trailing 6 months

Diagnoses

4 active
  • Colon cancer, sigmoid (Stage III)
    C18.7
    Chronic
  • Chemotherapy-induced neutropenia
    D70
  • Anemia, unspecified
    D64.9
    Chronic
  • Postsurgical malabsorption
    K91.2
    Chronic

Medications

adherence by PDC, last 90d
DrugClassAdherenceMonthlyFlag
Furosemide 40mgLoop diuretic
78%
$18Refill due
Carvedilol 12.5mgBeta blocker
92%
$24
Epoetin alfaESA (injection)
88%
$1,840Specialty
Sevelamer 800mgPhosphate binder
65%
$412Low adherence
Insulin glargineLong-acting insulin
84%
$286
Atorvastatin 40mgStatin
95%
$12

Pharmacy Opportunities

annualized
  • Sevelamer adherence outreach
    $6.2K
    Adherence 65% — risk of hyperphosphatemia admit
  • Generic substitution (Atorva)
    $480
    Already on generic — confirm DAW=0
  • Specialty site of care (ESA)
    $18K
    Shift Epoetin from hospital outpatient to home

ER Visits

6 visits / 12mo
DateReasonDispositionCost
2026-02-18Fluid overloadAdmitted$8.4K
2026-01-30HyperkalemiaDischarged$4.2K
2025-12-22Shortness of breathAdmitted$9.8K
2025-11-14Missed dialysis follow-upDischarged$3.1K
2025-10-02Chest painDischarged$5.4K
2025-08-19Cellulitis (AV graft)Admitted$7.1K

Inpatient Admissions

3 admits / 12mo
DateLOSReasonFlagCost
2026-02-184dAcute on chronic CHFIndex$28K
2025-12-226dVolume overload30d readmit$39K
2025-08-193dAV graft infectionIndex$22K

HCC History

CMS-HCC v24 / v28 · 3-year lookback
YearVersionHCCDescriptionRAFStatus
2025v28HCC 136Chronic Kidney Disease, Stage 50.289Recaptured
2025v28HCC 85Congestive Heart Failure0.331Recaptured
2025v28HCC 18Diabetes w/ Chronic Complications0.302Open
2024v24HCC 134Dialysis Status0.435Recaptured
2024v24HCC 23Other Significant Endocrine and Metabolic0.224New
2023v24HCC 108Vascular Disease0.288Open

Specialists

3 active
  • Dr. Priya Shah
    Med. Oncology · NPI 1295748394
    Last seen
    2026-02-12
  • Dr. Marcus Bell
    Colorectal Surg. · NPI 1487263903
    Last seen
    2025-11-04
  • Dr. Linda Park
    Radiation Onc. · NPI 1582039472
    Last seen
    2025-12-18

Care Gaps

HEDIS / Stars
  • HbA1c control
    Due Mar 12, 2026
    open
  • Annual Wellness Visit
    Due Apr 30, 2026
    open
  • Statin therapy (DM)
    Closed
    closed
  • Nephrology follow-up
    Due Mar 22, 2026
    open
  • Eye exam (diabetic)
    Due May 01, 2026
    open
  • Flu vaccine
    Closed
    closed

Annual Wellness Visit

Scheduled
Apr 18, 2026

Member Timeline

Unified longitudinal record · claims, ED, admissions, outreach & CM activity

  1. ✚
    Care MgmtCare manager note
    RN reviewed CHF action plan, daily weights initiated.
    2026-02-22
  2. ☎
    OutreachOutreach call — answered
    Discussed fluid restriction, scheduled nephrology f/u.
    2026-02-19
  3. 🏥
    AdmissionInpatient admission
    Acute on chronic diastolic CHF · LOS 4d · $28.4K
    2026-02-18
  4. ⚠
    ER VisitED visit
    Fluid overload → admitted · $8.4K
    2026-02-18
  5. ₪
    ClaimPharmacy fill
    Jardiance 25mg · 30d supply · $612 ingredient
    2026-02-10
  6. ₪
    ClaimSpecialist visit
    Nephrology — Dr. Mehta · CPT 99214
    2026-02-04
  7. ⚠
    ER VisitED visit
    Hyperkalemia → discharged · $4.2K
    2026-01-30
  8. ☎
    OutreachAWV outreach — voicemail
    Left message re: AWV scheduling.
    2026-01-24
  9. ₪
    ClaimSpecialist visit
    Cardiology — Dr. Vasquez · echo ordered
    2026-01-22
  10. ✚
    Care MgmtCase management opened
    High-risk CHF/ESRD enrolled in CM Tier 4.
    2026-01-08

Intervention Workflow

Care managers, nurses & physicians: launch interventions to capture savings, RAF and quality lift.

Estimated Savings
$0/ $42K
Estimated RAF Impact
+0.00/ +0.41
Expected Quality Impact
0 pts/ 16 pts