Payer Intelligence
National Health Financing · PeKa B40 · MADANI · MySalam
Plan scoreB+
Claims thru 12 Jun
what the AI gatekeeper kept out of the expensive end of the system
events good primary care should prevent · per 1,000 members
ACSC admissions (e.g. uncontrolled diabetes, COPD, hypertension) are the clearest signal of gatekeeping that is letting chronic disease slip.
cost concentration across the membership
Out-of-network leakage is the costliest leak - care the plan pays for at non-contracted rates because the gate could not resolve or retain it.
closing the gap during the gatekeeper encounter beats post-hoc outreach
flagged by trajectory model for proactive outreach before they become high-cost
Demonstration only. The scheme cohort, gate sites and members are synthetic and illustrative (currency shown in RM). The metric set follows standard payer practice - PMPM, medical loss ratio, gatekeeper containment, referral leakage, avoidable ED and ambulatory-care-sensitive admissions, clinical care-gap closure, a composite quality score and risk stratification - here applied across Malaysia's fragmented public financing (PeKa B40, Skim Perubatan MADANI, MySalam, PERKESO/SOCSO and the proposed MHIT) as a single analytic view. The payer's view of the MyZoyel clinics is as the gate: the AI primary terminal with point-of-care labs is positioned to resolve more on-site (containment ↑), close care gaps inside the encounter rather than via later outreach, and surface rising-risk members early - the levers that move PMPM, quality and avoidable utilisation together. Patient identifiers are not exposed to this analytic layer.