What Big D ata S hould D o for You: Requirements to Support Population Health

1© 2014 Valence Health. All rights reserved.

Clinical Integration

What Big Data Should Do for You: Requirements to Support Population HealthHFMA West Virginia Chapter

September 25, 2014



• Technology-enabled services since 1996

• National presence with 500 employees, 4 offices

• Serve IDNs, IPAs, PHOs, ACOs

• Serve 39,000 physicians, 120+ hospitals

• Support nearly 20 million patients

• Privately held

• 47% financial growth year over year

Valence Health – Lori Fox Ward, RN, BSN

Accountable Care

Population Health


• Senior Vice President of Strategic Initiatives• 20 plus years of experience in the managed care industry

working with providers and health plans• Leads implementation of population health management

programs for numerous provider organizations



Objectives

1 Understand What’s Fueling Big Data Discussions in Healthcare

2 Discuss Key Data Elements and Required Data Functions

3 Understand How to Use Data to Drive Actionable Results


Clinical IntegrationACA is Providing Incentives for Physicians and Hospitals to Align for Common Goals

Lack of Shared

Incentives

Lack of Physician

Governance

Fragmented Structure

• Long term contracts offered with no productivity terms or quality incentives

• Physicians were promised a greater say that was never delivered

• Hospitals failed to organize multiple physician groups into a cohesive units

• Lack of communication tools

Pre-ACA Implementation1 Post-ACA Implementation3

Aligned Incentives

Demand for Coordinated

Care

Technology Incentives2

• Bundled payments• Shared savings / risk

arrangements• Must manage care

together• Safe harbor for physicians

and hospitals to operate

• Penalties for poor quality scores for hospitals

• Staying on top of quality scores means improving physician relationships

• Meaningful Use initiatives provide incentives for investment in technology that improves coordination

• Overcome data issues

$

1) Deloitte Center for Health Solutions. “Physician-hospital employment: This time it’s different.” 2013. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd

2) Centers for Medicare & Medicaid Services. 2014 Definition of Stage 1 of Meaningful Use. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html3) PwC Health Research Institute. “From courtship to marriage: A two part series on physician-hospital alignment.” 2011. http://thehill.com/images/stories/blogs/pwc%20trust.pdf

http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd

http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html

http://thehill.com/images/stories/blogs/pwc%20trust.pdf

http://thehill.com/images/stories/blogs/pwc%20trust.pdf


Clinical IntegrationHealthcare Delivery Implications are Inherent with these New AlignmentsTrends are combining to create a fundamental shift in how we deliver and pay for healthcare services.

Element of Change PAST FUTURE

Health Care Focus Sick Care Wellness and Prevention

Care Management Manage utilization and cost within a care setting

Manage on-going health (& Optimize Care Episodes)

Delivery Models Fragmented / Silos Care Continuum & Coordination(Right Care, Right Place, Right Time)

Care Setting In office / hospital In-Home, virtual (e-visits, home monitoring, etc…)

Quality Measures Process-focused, Individual Outcomes-focused, Population based

Reimbursement Fee-for-service Value-Based (Outcomes, Utilization, Total Cost)

Financial Incentives Do more, make more Perform better, make more

Financial Performance Margin per service, procedure, etc.(bed, doc, etc.)

Margin per life



A Range of Technology Solutions May Be Enabled

HIE Population Health

EMR

PurposeTransmission of patient data across multiple systems

Clinically manage populations across the care continuum

Support individual patient/clinician workflows

Data SetsCCD, HL7 Claims, EMR Discrete clinical data,

CCD

Functions Patient Data movement

Pop Health workflow, risk stratification

Clinical workflow

Workflow None Mix of Analytic/Transactional

Transactional

RequirementsTechnical Network business Physician business

Data Model None Analytical Transactional

ImplementationOccurs largely in background

Background until go-live Pervasive impact on work

Target usersPhysicians, hospitals, data suppliers

Care Managers, Network Managers, and Physicians

Physicians in practice

Bu

sin

ess

Re

qu

irem

en

ts



What Makes “Big Data” Big in Healthcare

BIG DATA: DATA ELEMENT EXAMPLES

STRUCTURED DATA

UNSTRUCTURED DATA

SENSOR DATA

NEW DATA TYPES

CL

AS

SIC

EM

ER

GIN

G

• Small scale personal health records

• Insurance data

• Treatment data• Procedure data• Research data

• App & personal monitoring devices

• Telehealth information

• National electronic health records

• Scans, images, videos, #tweets

DATA ARCHITECTURE

HIGH VARIABILITY ANALYTICS

Extract, TransformLoad

External Data Internal Data

HIGH VOLUME

HIGH VELOCITY



Objectives





Clinical IntegrationBig Data’s Ultimate Healthcare Objective: Effective Population Health Management

Which populations?

Children ages 6 to 10 in zip codes 60662, 60607, 60615, and 60609

EX

AM

PL

E

What desired health outcomes?

What cost-of-care targets?

Key Questions to Inform Population Health Strategic Goals

Increase asthma control by 50%

Enable 100% of patients to self-manage via Asthma Control Plan

Reduce emergent ER/ED visits for acute asthmatic episodes by 30%

Supported and Validated by Population Health Analytics Enabled by Big Data Applications



Category Sample Use CaseClaims Data

Shallow and late

EMR Point Solution

Timely but incomplete

PH Mgt Platform

Balanced and useful

High-cost utilization

Which patients were seen in Urgent Care over the weekend?

Here are your patients who were seen in the ER… three months ago.

Here are the portion of patients that were seen at your hospital’s Urgent Care.

Here are all the patients that were seen in Urgent Care across you system.

High-risk clinical scenarios

Who are my poorly controlled diabetics?

Here are all patients with at least two diabetes claims with the same payor.

Here are some diabetics with a glucose >400, but only those who had a lab done by a staff physician

Here are all the diabetics with a glucose >400.

Pay for Quality (P4Q)

How am I performing on my HEDIS measures?

Here is how you performed 3 – 6 months ago.

Here is a calculation that bears no resemblance to your performance.

Here is your actual performance to date.

In Population Health, Timeliness, Precision and Comprehensiveness Matter

COMPARE: What Information a Physician Obtains from Different Data Sources

ADDITIVE BENEFITS: Timeliness and precision

Comprehensiveness



Key Functions to Support a Population Health Program

The following resources are necessary to meet functionality requirements:

# Functionality Required

Provide information to physicians/care coordinators on patients’ medical history, risks, gaps in care, and physician quality

Simply integrate with existing care management workflows

Succinctly provide quality and cost information

Integrate data across the entire provider network and continuum of care

• Timely integration of quality and cost data

• Data governance

• Nimble environment

• Business intelligence capability

Technology

• Dashboards

• Alerts

• Data mining

• Easy distribution

• Standard reporting

• Advanced analytics

Data

• Skilled analysts

• Technical support

Resources

1

2

3

4



Critical IT Capabilities for Population Health Management

Data aggregation from disparate sources• Including EMRs, hospital data,

demographics, lab data, claims, etc.• Across hundreds of provider locations

Advanced analytics and ad-hoc querying• High-risk patient identification• Quality dashboard• Reporting with only one-month lag time

Multiple views of care delivery and care management across the network• Patient-level, population-level• Provider, administrative

Evaluation of employed and affiliated provider quality performance• CIN measures performance• Primary care and specialist measures

At the Core of Population Health is the Ability to Capture, Aggregate, and Act on Clinical Information

1

2

3

4

IT = Information Technology, EMR = Electronic Medical Record, FTC = Federal Trade Commission

Clinical engine


Clinical IntegrationAttribution and Member Matching are Key to Data Integration in Population Health

Attribution assignment can be…

• Assigned by the payor or EMR

• Based on number and type of E&M codes

• Assigned using ranked specialists

• Triggered by Dx or Px

• More customized, if client wishes

Attribution is key to creating joint accountability for risk and quality. Configuration can be based on:

• Provider type: specialty type, PCP, PCP subtypes

• Single or multiple attribution: including groups as defined by geography or specialty

• By encounter detail: counts, types, and diagnoses specific

• Configurable at the measure level

• Any permutation of the above

Member matching capabilities reliably and accurately link unique individuals across EMRs, PMS, labs, Rx data, professional services, hospitals, and other institutions. Algorithms are:

• Tuned to enhance specificity and avoid false negatives

• High matching rates with capabilities for manual clinician directed merging

• Incorporate advanced statistical methodologies including probabilistic matching, Bayesian algorithms, and deterministic logic

Attribution Member Matching



Objectives






Data Analytic Requirements for Population Health

• Patient stratification

• Disease & Population management

• Population analytics

• Care management

• Gaps in care

• Episode and other groupers

• Patient engagement

Clinical

• Provider efficiency

• Quality reporting

• Incentive model

• Provider scorecards

Provider / Network Management

• Trends and predictive modeling

• Risk adjustment

• Contract performance

• IBNR

• Pro-forma modeling

Financial / Actuarial


Clinical IntegrationIdentify Populations With High Opportunity and the Methods to Manage Them

Capability Analytics Ideal State

1 Patient stratification Uniform risk adjustment for all payors

2 Disease and Population management

Creation of custom registries, patient and population tracking and outreach

3 Care management Robust workflow to facilitate CM functions across continuum

4 Population analyticsDetailed, integrated claims and clinical data to allow for complex analytics and the design of meaningful reports

5 Gaps in care Custom gaps in care

6 Episode and other groupers HCCs and other groupers uniformly applied to all payors

7 Patient engagement Proactive outreach alerts tool that is customizable

Clinical Analytic Requirements


Clinical IntegrationActionable Population Health Requires Timely Insights at the Administrative, Practice, and Physician Levels

Track Performance by Physician

CHF post discharge follow-up by physician

# of patients % Met overall % Met 14d visit % Met Card visit

2 CHF admits in 2012, but no outpatient visits?

Track Post-Discharge Follow-up

Track Admissions and Readmissions

7 CHF admits, 2 readmits <30d Globally or individually perform expedited outreach

Actively Track Patients with Overdue Care

Track Admissions and Readmissions

Jones, Martha

Peters, Anne

Tonks, Fred

Day, Camile

Schwartz, Saddie


Clinical IntegrationProvider and Network Analytics Provide the Quality and Cost Transparency to Effect Change


9 Provider efficiencyDetailed cost and utilization reporting at physician level, including peer and network comparisons

10 Quality reportingDetailed quality metric reporting at physician level, including peer and network comparisons

11 Incentive ModelConsistent and transparent incentive model in place so physicians understand requirements

12 Provider scorecardsScorecards which show timely quality and cost metrics, and are produced on a consistent basis and easy to understand

Provider / Network Analytic Requirements

19

Provider Efficiency Reports Identify Outlier Performers

Practice SummariesPCP=All PracticesClaims Incurred January 2013 - December 2013

PCP ID PCP Member Revenue Days/ 1,000

Inpatient Hospital Physician Total Drug Total Risk Risk-Specialty Months PMPM PMPM PMPM PMPM Medical PMPM PMPM Score Adjusted

PMPM PMPMALL 86,518 $334.41 203 $49.71 $62.44 $74.19 $201.57 $50.20 $251.76 0.8 $316.84

P06234 FP 1,596 $375.58 414 $44.45 $106.73 $71.74 $246.75 $26.76 $273.51 0.7 $389.36

P14342 FP 167 $446.57 - - $73.18 $63.75 $153.88 $7.32 $161.20 0.6 $258.63

P00166 FP 116 $416.87 - - $54.82 $78.08 $153.09 $57.88 $210.96 0.7 $295.30

P09942 IM 112 $315.50 - - $3.61 $27.04 $41.26 $14.12 $55.38 0.3 $169.55

P10192 FP 92 $617.26 - - $46.66 $92.53 $158.42 $135.30 $293.72 1.7 $174.91

P09294 FP 90 $582.73 7,200 $2,559.18 $974.77 $1,174.51 $4,797.89 $172.42 $4,970.31 5 $985.69

P08008 FP 77 $300.49 - - $5.10 $20.35 $36.07 $21.53 $57.60 0.4 $164.33

P01879 FP 72 $240.84 - - $9.13 $25.25 $44.99 $0.00 $44.99 0.8 $53.99

P13966 FP 71 $571.19 - - $29.37 $176.90 $219.39 $82.42 $301.81 1.3 $238.89

P11479 FP 70 $422.80 1,371 $16.17 $86.72 $70.64 $185.54 $147.80 $333.33 1.5 $215.81

P18376 FP 69 $394.68 - - $26.85 $28.20 $65.66 $22.35 $88.01 0.8 $108.95

P07978 IM 64 $464.79 - - $265.05 $224.64 $514.57 $23.95 $538.51 1.3 $399.64



• Includes meaningful indicators of quality

• Attributes patients to physicians in a way that I trust

• Enables users to understand & improve the quality of care

provided to patients• Sufficiently incorporates

benchmarks & targets• Provides intuitive and actionable

reports & dashboards• Allows users to drill down easily

& sufficiently• Compares performances across

providers/practices in a valid manner

• Will allow my organization to display its value-based business case (i.e. organizational performance)

Quality Measures Module

Quality Reporting Provides Network Performance Comparisons

Desired Attributes for Quality Reporting

Physician Drill Down Capability



Using Data to Evaluate Overall Performance


13 Trends / predictive modelingDetailed claims level data will allow trend analysis and predictive modeling capability

14 Risk adjustmentUniform risk adjustment for across entire at-risk population (may include multiple payors)

15 Contract performance Produce own reports to assess recent performance

16 IBNR Estimation of pending claims that have not yet been received

17 Pro forma modeling Detailed claim level data for robust modeling

Financial / Actuarial Analytic Requirements


Clinical IntegrationPerformance Insights into the Cost and Quality of Care

Manage value-based contracts• Attribute / allocate costs in a meaningful

way

• Understand and optimize cost-effectiveness of care provided to patients

• Compare cost over time vs. cohorts vs. benchmarks

Analyze medical costs and trends• Compare cost over time vs. cohorts vs.

benchmarks

• Understand and optimize the utilization of healthcare services within the network

• Avoid unnecessary cost and utilization (i.e. duplicative tests, services, etc.)

Track medical expense across major expense categories• Catastrophic claims

• Medical claims distribution

• Profile physician performance on cost and utilization

• Profile practice performance on cost and utilization



Data is Only One Piece of the Puzzle

• Program development• Analytics• Reporting and tracking• Risk alignment and mitigation• Continuous communication of quality

• Data capture• Cross-continuum, evidence based practices• Access to care• Clinical quality and resource utilization

Population Health Management RequiresDedication to Daily Operational Excellence

• Definition of population and determinants of health• Uniformly defined quality standards• Communication• Health promotion and prevention• Equalization of access, outcomes, cost

ONGOING ANALYSIS AND PROGRAM REFINEMENT

Care Delivery

Policy Management



Vision

vQuest

Care Manager

Health Plan Services

Population Health Management Solutions

• Clinical Integration• Quality Measures• Population Health for

Multi-TIN Settings• Registries

• Medical Cost & Utilization

• Risk Adjustment

• Case Management• Care Coordination• Patient Outreach

• Claims Processing• Premium Billing• Provider Portal• Member Portal

Thank You for Your Time TodayFor additional questions and comments, please contact Lori Fox Ward at [email protected]

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