Healthcare Provider Analytics and Reporting: Expanding Beyond VBC Use Cases
We will release our newest report, 2019 Healthcare Provider Analytics Market Trends Report, in the next few days. This report reviews the current market for provider analytics and evaluates offerings from 23 different vendors.
In recent years, providers invested in analytics technology to support the transition from fee-for-service (FFS) to value-based care (VBC). Vendor offerings that support the variety of pay-for-performance (P4P), pay-for-reporting (P4R), and risk-sharing programs with payers have helped them better understand the interaction of costs, quality, and utilization in the populations they serve. But the applications for analytics are broader than just VBC. Provider healthcare organizations (HCOs) are seeking to leverage these technologies more broadly to support a range of clinical, financial, and operational performance improvement goals and programs.
Provider-oriented analytics availability mirrors EHR penetration. Providers in acute and ambulatory settings have many choices for analytics across multiple use cases. Providers in post-acute settings and others with low EHR penetration have relatively fewer choices. While vendors have devised a number of ways to extend their offerings to underserved settings, not all providers take full advantage of such capabilities.
EHR vendors are often, but not always, providers’ first choice for analytics. Most EHR vendors sell analytics offerings almost exclusively to their existing EHR customers. Independent vendors – not owned by an EHR vendor or a payer – are a strong alternative to EHR companies for value-based care use cases. Claims analytics companies have deep experience with claims data sources or rely heavily on claims-related data to fuel analytics and reporting. Applications from many of these vendors emphasize cost and utilization control and feature deeply descriptive insights into risks, costs, quality, and utilization. Providers have historically been reluctant to adopt these offerings, but that is changing.
This report characterizes current analytics solutions as either “mainstream” or “advanced.” Most HCOs have experience with mainstream analytics – often cloud-hosted and reliant on relational databases that store historical data from the EHR, claims, and other sources. The resulting applications characterize and summarize performance along multiple dimensions. While this technology approach is well-established, mainstream analytics still faces challenges. Chief among these are data quality and variability. Diligence is required on the part of vendors and HCOs to ensure this data is accurate, high-quality, and up-to-date.
Data complexity challenges are only increasing because new data sources are on the horizon. The All of Us program (formerly known as the Precision Medicine Initiative) promises to unleash a torrent of novel and voluminous data types. In addition, the vast trove of unstructured data in EHRs will soon contribute to a better understanding of patient cohorts and risks. Social determinants of health (SDoH), data from smart health monitoring and fitness devices, and a variety of patient-reported and publicly-available data sets are also beginning to be used in provider analytics.
Mainstream analytics has yet to supply a variety of predictive and prescriptive insights; for that, HCOs are looking at advanced analytics.
Advanced analytics consists of interrelated technologies, the most common of which are artificial intelligence (AI)/machine learning (ML), natural language processing (NLP) and extraction, and big data technologies. These technologies and techniques are not widely deployed in healthcare, but are used to varying degrees by most of the vendors profiled in this report. The expectation is that as these technologies mature, advanced analytics will offer more and better predictive and prescriptive capabilities. Many vendors now offer optional services to help providers take better advantage of advanced analytics technologies. Increased organizational familiarity with AI technologies and algorithms should naturally increase user trust as the technologies mature and become more widespread.
Many provider organizations, with experience gained from their VBC efforts, want more benefits from analytics. Whether it is from their legacy point and departmental reporting solutions, mainstream, or advanced analytics, provider organizations see analytics and reporting as a reliable way to pursue performance improvement goals across their enterprises.
Matt Guldin · 2 years ago
Liz Gavriel · 4 years ago
John Moore · 2 months ago
Brian Edwards · 3 months ago
Brian Murphy · 2 weeks ago
Analytics – An Integral Part of Care Management Success
Last week, I attended the 3rd Health Analytics Summit (HAS). This was my first time attending an event that now attracts over 1,000 attendees. Providers were well represented at the event with nearly 80 percent of the attendees coming from various provider HCOs.
While Health Catalyst focuses on analytics, my observations were largely focused on the care management related aspects of the conference. Here are some of the main impressions from the event:
Line between analytics and care management has blurred further: In our Care Management Market Trends Report, there were some analytics-focused ratings criteria with ‘Risk Identification and Stratification’ being the most straightforward analytically-oriented criterion.
More HCOs though are moving beyond simply importing a risk score from a claims-based risk grouper solution as explained in our Insight Report on the topic. They use this as a starting point, utilizing other data types (mainly clinical and utilization data) to define their own proprietary risk groups including sub-groups within high-risk patients.
Additionally, HCOs are leveraging analytics to measure the effectiveness of their care management programs ‘early and often’ – instead of waiting 9-12 months to examine clinical and cost-based outcome measures. They are also looking at more implementation and process-based measures to assess program effectiveness of particular care plan elements before expanding them to other patient types.
New data are ‘sexy’ but existing data issues consume lots of bandwidth: One of the first poll questions asked was which new data sets were the attendees most interested in for analytics-related projects with the top 3 being: social determinants, patient-reported outcomes, and external demographic data (e.g., credit scores). There was not much difference between the three although most of the conversations I had or heard really focused on the gathering additional social determinants of health especially related to the patient’s home after discharge and what resources were available to a patient.
But clinical data quality and to a lesser degree claims data still remain the biggest issue. HCOs are spending 30-40 percent of time on this single issue during the first several months of a project. Combine this with a multitude of varying and ever-growing value-based performance (VBP) measures, it is no wonder that incorporating additional new data sets into various analytic initiatives is challenging.
Provider-led care management adoption reaching a tipping point: One of the more difficult things to determine is just how many HCOs have actually put a care management program in place in their outpatient settings. There are several different ways we have heard HCOs define this but the most standard definition is having care teams headed by an outpatient nurse care manager who actively manages some percentage of an HCO’s patients through a care plan.
At the Partners HealthCare session on their care management strategy, which Health Catalyst has licensed the IP of, nearly two-thirds of the respondents indicated they had a high-risk primary care management program already in place at their HCO. The conference attendees likely represent some outliers but it would not surprise me if the actual adoption rate for care management among hospital-based HCOs is already at or exceeds 50 percent by early 2017. This number is likely considerably lower in rural settings, community hospitals, or among physician-based HCOs.
There is not some clearly-defined threshold in which an HCO decides to put in place a care management program but the two most useful anecdotal metrics seems to be: number of primary care lives under value-based reimbursement programs (VBR) (est. >15 percent of primary care lives) and percentage of total revenue in VBR arrangements (est. >20-25 of total HCO revenue).
HCOs actually engaging in longitudinal care management for a cohort of patients: While more HCOs have put in place care management programs, the overwhelming majority of these programs are not truly long-term, continuous care management programs. Instead, the vast majority of them are based around enrolling a patient for a finite duration of <30 days, <90 days or <120 days.
This should not be surprising given that HCOs are rationally responding to the measurement periods of various VBP programs most notably the Hospital Readmissions Reduction Program (HRRP) program from CMS. Partners Healthcare detailed how they are engaging in care management for a cohort of high-risk patients from several different payer types including Medicare Advantage, Commercial, Managed Medicaid, and their own employees and dependents.
If provider-led care management programs are going to bend the cost curve, continuous care management including palliative care for end-of-life patients is going to be necessary. Simply focusing on inpatient admission rates is going to be insufficient given early ACO results. The question is how many HCOs have the financial and clinical resources, geographic coverage, and economies of scale to accomplish this lofty goal especially in regions where there is considerable patient churn (e.g., +20% annually).
Broader integration is key for care management: Time and time again access and timely integration with behavioral health services is becoming a critical issue for the success of care management programs. Partners Healthcare reported that nearly 40 percent of their patients in care management program had at least one behavioral health issue. This is not uncommon and several other HCOs have reported to us that 30-50 percent of their patients have at least one behavioral health issue beyond something that can be treated by a primary care provider (PCP).
It is critical that when these patients come in for an office visit to their PCP or seek access to behavioral health services that these resources are available in-person or via a telehealth consult. Other additional areas that are coming up as being critical to provider care management programs for high-risk patients, are tighter integration with substance abuse, pharmacy, and palliative care resources.
Most attendees at the Population Health Summit indicated their HCOs were in the early to middle stages of integrating analytics across their organization with varying degrees of success. Attendees overwhelmingly felt these efforts were having overall positive effects on quality even if ROI remains challenging to determine. Most surprisingly, attendees self-reported that adaptive leadership and culture was the highest-scoring attribute in Health Catalyst’s recently-released Organizational Improvement Readiness Assessment with analytics and best practices being the lowest scoring attributes.
What stuck with me though was just how pervasive analytics are to not only defining the foundational requirements for a care management program but the crucial role they play in helping to set up, refine, and support a care management program over time. Unless a care management program is using analytics to actively measure ‘early and often’ and using this feedback to effectively optimize care management processes, results will be limited.
Without Communication, Coordinated Care Is Still Just Care
Back in October, I tore my left calf in the middle of a marathon. Like any crazy runner worth his weight in energy gel, I still finished the race, even if it meant limping around for the rest of the day and driving myself to urgent care when I woke up the next day with a purplish-red mark on my leg. This marked my first foray into the medical system (aside from my annual physical) since I whacked my head on a beam in my basement several years ago and needed staples in my head.
More than two months and nine physical therapy visits later, I’m back to running – albeit at a slower pace and for shorter distances than I’m used to, but luckily with no staples anywhere on or in my body. The whole ordeal provided me a nice introduction to care coordination – and illustrated all too well just how immature the process remains.
I made sure to visit an urgent care facility affiliated with my primary care provider’s network. (It’s one of the large ones in Boston.) The physician who saw me, as well as the discharge nurse, noted that my records would be passed along to my PCP. I’ve yet to hear from my PCP – but, in his defense, an otherwise healthy young man suffering a minor injury with a slow but straightforward recovery process likely (and rightly) ranks low on his priority list.
To the credit of my health system, the record of my urgent care visit appears in my portal, too. This I learned the hard way, though; no one at the clinic told me to look there. I’m willing to bet I’m in a small minority of patients who can find a) the URL for the portal, b) the password for the portal and c) records within the portal. This lack of communication hardly presents the same severity as an open care gap, especially given my condition, but it does show that volume-based health systems care more about seeing the next patient than fully empowering the current patient.
From there, I went to an orthopedist referred by the urgent care physician. No record of that visit appears in my portal. Nor, for that matter, do any of my subsequent visits to physical therapy. In other words, my record is incomplete. Absent any sort of longitudinal care plan, one could easily get the impression that I went to urgent care and ignored doctor’s orders instead of seeking the most appropriate treatment for my condition so I can run the Boston Marathon for the first time this spring.
No one is at fault here. The urgent care physician was honest, the orthopedist direct, my therapist thorough. I have no complaints about the care process at all. The problem is that – contrary to what any slide deck from a vendor, government agency, professional group, or healthcare organization will tell you – there is no solid line between caregivers of this type. There is no precedent for them to communicate, just as there is no precedent for anyone at urgent care to tell patients before they hobble out the door on crutches to check their portal.
Sure, a financial incentive may motivate any of those caregivers to share a note that says, “Hey, Brian’s recovery is going well.” So, too, might a Direct-based messaging system that integrates with whatever software program those caregivers use most during the course of their day.
However, until the healthcare industry recognizes that its care management problem is, above all, a systemic communications problem that fails to capture and document the verbal and nonverbal care narrative, a truly coordinated care process remains rare – as rare the injured runner who actually waits to go for his first jog until his physical therapist says it’s OK.
The Promise of Consumer-Driven Health
As John pointed out last week, I’m the newest member of Chilmark Research. I’ve joined the team to wrap my head around the role of the patient/consumer/citizen in the healthcare process. This role has changed dramatically since I started covering health IT in late 2009. Heck, it’s changed a lot in the last five and a half months, let alone the last five and a half years. That said, I’m thrilled to have an opportunity to learn more about it.
Looking back, no single, seminal moment piqued my interest in consumer health. My medical history is free of lengthy hospitalizations, chronic conditions, or bad accidents. Even in August 2010, when I was rear-ended at a stoplight and my Ford Focus was sandwiched between two SUVs, I stepped out of my crumbled car with only a bruise, an airbag burn, and a sore back. I am, in a word, lucky.
Many others are not. You can’t cover health IT – and, more broadly, healthcare – without coming across people who suffer tremendously, whether from the physical pain of their conditions or the emotional pain of relying on a system that’s at times cold, complicated, and uncaring. With a curious mind like mine, you also can’t help but wonder if there’s a better way.
The authors of the Affordable Care Act (ACA) seemed to think so. Amid the reforms that have caused so much recent controversy stands a noble idea with which few people disagree: Healthcare works a lot better when it actually focuses on the person who needs care.
Broadly speaking, two principles guide this idea. The first is that patients/consumers/citizens should take greater ownership of their care. That’s the proverbial carrot. The second is that, to motivate them to make the types of healthy decisions that help them avoid system utilization in the first place, they should also share in paying for the cost of their care. That’s the stick, and it’s often described as making sure consumers have “more skin in the game.” (That’s up there with “Uber for healthcare” on my list of catchphrases that need to disappear.)
The years since the passage of ACA have given consumers far more sticks than carrots. Yes, we’ve seen price transparency, accountable care, pockets of payment reform, and an explosion of health and wellness technology, but we’ve also seen narrow networks, exorbitant out-of-network fees, high-deductible health plans, rising premiums, and an endless supply of jargon-filled paper discharge summaries and explanations of benefits. None of these sticks have a positive effect on the care delivery process and certainly not on ultimately improving the patient experience.
Why, then, am I thrilled to join Chilmark Research? I devoted most of my first several days at Chilmark to reading about the latest trends in consumer-driven health – value-based care, wellness programs, telehealth, direct primary care, retail clinics and anything else that caught my attention. I learned a lot from that research, but ultimately it boils down to this: For every problem that today’s healthcare citizen faces, you can find dozens of players of all shapes and sizes searching for and/or proposing a solution.
Making sense of this growing market will be a challenge. Fortunately, as someone who runs marathons for fun – even and especially when it means training through a cold, snowy New England winter – I clearly like a challenge.
As I familiarize myself with the wide world of consumer health, I look forward to sharing the insights from my curious mind, always with the goal of helping market leaders in the healthcare industry use technology to improve the patient/consumer/citizen experience. In the meantime, feel free to drop me a line.
Inside Peek at Forthcoming PHM Report
Over the last several weeks, I have been working feverishly to finish our first major report on Population Health Management (PHM), which is now in production. It may appear that we are a little late to the party in providing thoughtful research and analysis on this topic, but honestly, PHM is so nuanced, solutions remain immature and industry best practices have yet to develop, that upon reflection, timing of this report seems just about perfect.
Following are just a few of the insights gleaned from this report.
PHM is Top of Mind
Population health management is now at the forefront of strategic initiatives being undertaken across the healthcare industry. Prompting these strategic initiatives is the massive shift in risk, via payment reform, from payers to providers that is likely to completely redefine the health care delivery system in the U.S. However, the challenge is that by and large, the healthcare sector today is ill prepared to make this transition to a PHM model of care delivery.
There are a number of challenges that stand in the way of healthcare organizations’ (HCOs) adoption of PHM-centric strategies:
Our PHM Perspective
For the purposes of this forthcoming report, we define population health management as:
The proactive management of the health of a given population by a defined network of providers who are financially linked, in partnership with community stakeholders (e.g. social workers, visiting nurses, hospice, patient, caregivers/family, etc.).
Within that short definition there are three important concepts. The first is that providers will move from the current passive management of patient and population health to one that is proactive. Second, that PHM occurs among a defined provider network that is financially linked, in most cases via a contract with a payer or self-insured employer entity. Lastly, that the care team extends beyond the provider(s) to include a community network of stakeholders that play a role in the care of a patient.
While Still Immature, Health IT to Support PHM is Evolving Rapidly
The healthcare industry has been slow to move to a digital, data-driven model of care delivery. It has only been in the last six years that a serious effort has been made industry-wide, via federal incentives, to adopt electronic health records (EHRs) to support the creation of a digital, patient health record. Proficiency in the use of EHRs is slowly improving. However, the industry struggles with a host of issues, from clinical data quality to interoperability across a heterogeneous EHR landscape, to supporting dynamic care teams, all of which will create significant challenges for any PHM program.
On the IT vendor side of the fence, while countless vendors claim to have a PHM solution, none can provide a complete solution today. Therefore, HCOs will be left with the challenge of knitting together best of breed solutions to enable their PHM strategy. Core PHM technology capabilities must include:
The EHR will play a key role in PHM initiatives as a core system for the patient record, but a number of HCOs today are unfortunately using the EHR as the core solution for PHM.
PHM is not about one provider, one HCO and therefore one EHR. Population health management requires the active engagement of a multitude of stakeholders across a community all sharing data in support of care delivery processes, regardless of care setting. Monolithic, EHR-centric PHM programs will prove unsustainable over the long term.
Other solutions, such as those to address care management and coordination across a community remain quite immature. A number of payer-centric, care management solutions are pivoting to address provider requirements, but by and large, few have been successful to date.
Patient engagement, despite a significant amount of marketing hype, also remains very immature, largely as a result of its relatively low priority for HCOs’ IT investments, and more logistically because of its unclear home in HCOs’ workflow processes.
In the near term, the greatest focus of resources to support PHM will be targeted at analytics and CNM. The adoption of analytics solutions and services is quite strong today, especially among larger HCOs, to assess population risk, stratify that risk and measure performance. Within the industry as a whole though, the ability to attract and retain data scientists is proving challenging. This has created opportunities for solution vendors to provide complete bundled solutions, including sophisticated analytics services.
But performing data analysis is of little use if it is not proactively used. Delivering data insights to the point of care (PoC) will play a crucial role in a PHM program’s success. Leveraging CNM to enable distribution of analytically derived insights to providers across a community has the potential to dramatically improve quality, reduce variability and improve outcomes.
The lack of maturity within the healthcare sector in developing and deploying the processes, systems and technologies to support PHM will result in a strong market need for solutions that have a strong services component. However, due to severe resource constraints, healthcare organizations will increasingly look for highly modular solutions that allow them to pursue a piecemeal approach to enabling core functions in support of PHM.
Currently, we are seeing strong convergence on a per member per month service pricing (pmpm) model, often times broken out across an array of modules that a vendor may bring to market. Such a model accomplishes two goals. It allows HCOs to incrementally add functionality that aligns with their PHM priorities and budget constraints. Secondly, this model provides a high degree of flexibility for solution vendors to match pricing to the amount of services provided and is particularly amendable to hosted-service models.
Looking further out, however, HCOs will increasingly look to their solution providers to potentially share in some of the risks as well as rewards that may come from adopting their solutions. Over the course of preparing this report, we came across some examples of such, but this is very experimental at this point in time and such contracts are quite narrow in scope.
There still remain a significant number of questions as to how the PHM landscape, both for providers and their solution vendors will evolve over next several years. This upcoming report is just the beginning of our significant, future research on this topic.
As the market develops, Chilmark will continue to delve deeply into what successful PHM initiatives look like and just as importantly, what are the lessons to be learned from unsuccessful PHM programs. There remains a significant amount of uncertainty in how PHM will develop and it is our mission to assist the industry, through our research, in understanding what path may be the most fruitful for any HCO to follow on its journey to PHM.
Stay tuned – the shift in risk from payers to providers and the adoption of PHM strategies to successfully manage that risk will keep us all quite occupied for some time to come.
Expanding the Clinical Network for Value-based Care
The provider world is dominated by organizations that believe in a slowly evolving status quo that will somehow carry them across the threshold of accountable care to a fully formed world in which VBR-compliant ways of delivering healthcare solve their sundry problems. These status-quo organizations remain wedded to fee-for-service (FFS) and have not begun to focus on the inevitable shift in risk from payers to providers under future value-base reimbursement (VBR) models.
There are a select number of forward-thinking HCOs that are actively preparing for VBR and the day when revenue depends on how well they deliver care to the individual patient and panels of patients as a whole over time – not just episodically. However, these forward thinkers represent an exceedingly small proportion (5-7%) of all HCOs in the U.S.
An area of weakness we find across HCOs, including a few forward thinking ones, is a lack of core competencies in a number of areas that have been the domain of payers and will be critical for success under VBR including: actuarial analysis, benefit design, utilization management, authorization management, disease management, consumer marketing, and similar functions. One could debate consumer outreach and marketing, but by and large, even here payers have done a better job than most HCOs
Providers of both the progressive and less progressive variety will find that their ability to thrive under VBR depends on how well they perform these functions. Some provider organizations see VBR as a way to disentangle themselves from payers without realizing that they will wake up one day and find that they have become the payer.
These new functions that providers will be required to adopt will ultimately have to be incorporated into clinical operations even though the current crop of clinical applications (e.g., EHRs and HIEs) is arguably not up to the task. HCOs preparing for VBR will find themselves at worst hamstrung or, at best, minimally supported by their clinical vendors.
The longtime focus of clinical application development has been on the physician and, to a lesser extent, the nurse. The point-of-care has been where the money is for EHR and HIE developers. No one can dispute that the physician-patient interaction is the central and most important element in a clinical visit. Every clinical intervention flows from that interaction. However, an office visit consists of multiple interactions between the patient and the HCO. Patients, in a single visit, interact with many people: front office staff, nurses, phlebotomists, radiology technicians, nutritionists, care managers and a host of others. The idea of team-based care requires that EHRs and HIEs do something they aren’t that great at: provide a point-of-care focus for the individual clinician as well as a point-of-encounter focus for the HCO.
When we look at introducing functions formerly performed by payers into clinical operations, the point-of-encounter perspective rises in importance. Under VBR, clinicians will make clinical decisions based on the facts and circumstances of the specific patient and based on past experiences with that patient. The specifics of follow-up care and the composition of a care team will depend on the benefits design and utilization patterns of the patient and the patient’s risk panel.
Instead of sweating out an authorization from a payer for a particular clinical intervention, individual clinicians will be responsible for following evidence-based care plans enforced by the HCO through the EHR/HIE. Instead of letting the payer control where patients are referred, providers will want to keep referrals in-house and away from competing providers.
The irony, at least for now, in this is the volume imbalance between administrative payer-provider transactions and clinical inter-HCO transactions (via HIE and other mechanisms) that are occurring today in a HCO.
Payers have invested heavily in transaction-oriented networks to support all of the things so feared by providers: authorizations, claims presentment, referrals, eligibility determinations. A significantly smaller volume of inter-enterprise clinical transactions, on the other hand, are flowing between HCOs to support a relatively narrow range of point-of-care clinical activities. We think that EHRs and HIEs will have to adopt a view and development focus that looks at the totality of information needed to support a clinical encounter — patient clinical data, administrative data and panel level data — to really support HCOs on their voyage from FFS to VBR.
Financial Analytics Bleeding into Population Health Management
It appears that “population health management” (PHM) just has a better ring to it than “accountable care” or “HMO 2.0”. Increasingly, PHM is becoming an umbrella term for all of the operational and analytical HIT tools needed for the transition to value-based reimbursement (VBR), including EHR, HIE, Analytics, Care Management, revenue cycle management (RCM), Supply Chain, Cost Accounting, … .
On the other hand, HIT vendors continue to define PHM according to their core competencies: claims-based analytics vendors see PHM in terms of risk management; care management vendors are assuming that PHM is their next re-branded marketing term; clinical enterprise data warehouse (EDW) and business intelligence (BI) vendors argue that a single source of truth is needed for PHM; HIE and EHR vendors talk about PHM in the same breath as care coordination, leakage alerts and clinical quality measures (CQM); and so on.
We at Chilmark have not articulated a single vision for where PHM ends and all other VBR related HIT begins for the simple reason that “It Depends.” It depends on where you are starting, it depends on your existing IT infrastructure in place, it depends on the community you serve and the structure of your clinical team (acute, ambulatory, long-term care, affiliate vs owned mix, etc.). There is not an easy answer here.
That being said, we are in the process of articulating these issues in a forth-coming Insight Report and it appears that Dale Sanders, SVP at Health Catalyst, has jumped the gun with his own articulation of PHM and what is required to be successful in his recent Population Health Management report.
Note: Vendor-produced papers that rank the sponsoring vendor in question as the top dog are often easily dismissed as biased, despite any claims of impartiality on the part of the author. This one I found worth the read, however, despite such bias.
Sanders’ initial few paragraphs did a good job of clarifying the difference between, as he puts it:
However at this point in time, there is a huge disconnect between groups dedicated to PHM — quality and care mgmt. groups — and those dedicated to financial & risk mgmt. In one recent conversation with an HCO executive, he mentioned a HCO in their region that had aggressively moved towards VBR, a push by senior executives including the CFO, that was ultimately rejected by clinical executives leading to exodus of CFO and a number of other executives. This division between clinical and financial leads us to propose the following Venn that represents where we are today.
As the above diagram shows, we are seeing the line between PHM and financial mgmt. blurring over the last few years. Network leakage, total cost of care, utilization KPIs, risk scoring, etc. are increasingly being discussed in the same breath as PHM.
These financial data are desired by HCOs to better manage population risk — across both care management and performance management functions. For example, a care manager might wish to view the predicted total cost of care for a set of high-risk patients; or a risk manager might want a dashboard that combines paid-claims-based risk scores with clinical-based quality measures.
Going forward, I don’t know if financial departments within HCOs will ever become fully united with clinical teams under the common purpose of PHM and more broadly, VBR. I however do see the “bleeding” increasing, as cost accounting systems, and elements of RCM and staffing become more intertwined with PHM needs in support of a VBR strategy.
My upcoming 2014 Population Health Analytics report will explore these and many other trends further… and thanks to Dr. Sanders for the catalyst to write this post.
Claims Data is NOT a Trojan Horse
Probably the most notable development apparent at HIMSS14 was how much HIE and interoperability vendors are now talking about including claims data in their solution sets. Last year at this time, most of these vendors questioned the clinical value and utility of claims data at the point of care. In contrast, this year HIE vendors are now talking as if claims data were as liquid as orders and results between provider organizations. This is a positive, if somewhat overstated, development on the part of the vendors.
In mid-2013 we did see quite an uptick in interest on the part of payers to become more directly involved in HIE initiatives. This interest continued to accelerate through the remainder of 2013 as payers felt that they did have valuable information to contribute, such as eligibility checks when patient is being admitted to ER or information on patient follow-up post discharge and prescription refills (medication compliance). Some of this information, e.g. eligibility check can be provided in near real-time to a patient’s primary care physician.
While vendor support for claims data exchange points to the general increasing level of support for the evolution to value-based reimbursement (VBR), the problem with claims from the provider perspective is history.
Payers until now have been the gatekeepers-to-money translating in the minds of doctors, nurses and patients as gatekeepers-to-care. Payers have wanted better access to clinical data for decades but provider organizations do not want payers poking around in their clinical data. This is not the opinion of most providers, it is still the opinion of every provider we’ve spoken to. This stems from simple distrust of payer motives and the fear of ultimately having their data used against them, which regrettably has happened in the past.
Another challenge has been payers unwillingness to share data outside of a specific VBR contract. In numerous calls we have had with clinical executives, a common refrain has been that payers hold-out on sharing data unless there is something in it for them. Not exactly altruistic or in the best interests of providing quality care across a community.
Most provider organizations are only too happy to get specific about the limitations of claims data and further entanglements with payers through claims or other kinds of data:
Claims data is not that current
Most of the provider organizations we talk to maintain that the payers can only provide accurate data for things that happened six months ago. Anything of a shorter time horizon than that is subject to revision and therefore of very limited value. The exception to this is the aforementioned eligibility checks wherein a provider organization can receive near real-time visibility into network leakage.
Claims data is hard to work with
Providers correctly point out that most payer data sits in 1960s- and 1970s-era mainframe databases and file systems and is processed nightly by COBOL batch applications. While payers use this data to send lots of paper reports to providers, few providers have figured out how to use this data to improve patient care. Instead, this kind of payer data mostly just adds to the fog of data surrounding patient care and is by and large ignored.
Payers motives are suspect
Payers like to create the impression that they make healthcare happen for patients even though they do not provide the full suite of healthcare services nor do they appear to serve patients/members in a manner to truly help them with their healthcare issues. On this point, members share provider views and have strong distrust of payer motives.
Challenges Using Payer Data
Provider organizations will have challenges using claims data in the here and now. Looked at from what happens at the point of care, providing physicians with tools that somehow integrate financial relevance into the practice of delivering quality care is not something that most organizations are really prepared to do. From a more narrow technical perspective, the EHR’s ability to accept this data and make it relevant and actionable for front-line clinicians in their workflows is also something that providers (and by extension their HIE and EHR vendors) will need to address.
Benefits to Providers
But VBR is coming and payers are in a position to help solve some of the soon-to-be or already vexing problems for many provider organizations: revenue leakage, patient risk scoring, care gap identification, medications adherence, clinician performance management, care management or population health.
Solutions to these problems will provide a range of different benefits to provider organizations but genuinely hard to incorporate gracefully into clinician workflows. In addition, solving these problems will require more than just the payer claims data. A range of payer-derived data types will be needed to help provider organizations.
Changing Dynamics of the Payer-Provider Relationship
The use of payer-derived data is inevitable and providers need to look at potential silver lining. Some providers are actively talking about using payer data to evaluate and compare health plan benefit design. The thinking is that by comparing similarly situated patients from different payers from an outcomes standpoint, they may be able to link specific features of a benefit plan (e.g. free annual physical exam by PCP) to better outcomes. If the outcome variance from payer to payer is not minimal then maybe there is a member-benefit design problem that they need to raise with the payer. More importantly, it might put the provider in a better position to recommend to their patients the most effective health plan based on the patients’ overall health history. Using the same logic, providers could compare the performance of partner provider organizations as an aide to negotiation with those partners.
The point is that provider organizations need not view the use of payer-provided claims and other data as all downside. Claims data is as good a place as any to start building trust between traditional adversaries.