At Health Datapalooza: Transforming Claims Data in to Quality and Cost Part I

sgruber-200 (1)By Sarianne Gruber
Twitter: @subtleimpact

Claims data is incredibly noisy and unless you really understand what the is question that you are trying to answer, there is a high likelihood that the data that you pull to answer the problem is going to be the wrong data,” Ariel Bayewitz, Vice President of Provider Analytics at Anthem, unequivocally told the audience.  Despite the onerous task of working with claims data, the Health Datapalooza panelists presented  their organization’s success turning this messy data into actionable and reliable information for the end user whether consumers, providers, payers and health systems. Here is a synopsis of challenges each organization or corporation is trying to meet with their clients and the benefits they were able to deliver. The panel moderator was Francois de Brantes of HCI3 and distinguished panelists included:

Cost of Care Trends for Customers
You have multiple customers, some are internal customers, and some work with networks, providers that you contract with as well as employers and plan members. What do they want?

Mr. Bayewitz replies “two things”.  Number one, customers want to understand what is driving the cost of care trends.  You would look at their prior claims experience.  It’s not just unit cost.  It is all the costs of across the continuum of care.  They are looking at their Per Member Per Month (PMPM) cost for their population last year and compare it to the PMPM this year. They want to know why is it going up or why is it going down.  Unit cost is less important than it used to be; still it has a major effect on what is driving PMPM.  They could notice on the outpatient side costs are going up. Perhaps the ER or Surgery is driving costs.  Maybe the story could be that unit cost is going up because they are paying providers more.  One really needs to parse out the piece that is unit cost related.  What is the cost per service from the other elements which may be related to utilization?  It could be that there is more volume in ER in certain geographies because they don’t have the right primary care network in those geographies, and specifically which geographies.  It could be due to a high number of frequent flyers or a variety of other things.  Customers really want to understand from the data top down, from a trends standpoint, to see where the movement is directionally.  What specifically is driving that unit cost utilization? What is the type of service, who are the specific providers and which geographies?  The answers to why the PMPM is changing are fairly basic.  Second, what employer groups are demanding relates to cost transparency. They want to enable their members with information to help them make the right decision at the right time.  And there are a lot of technologies that try to do it, but I there is a huge gap where we are today and where we can be.   If a patient is trying to find out which cardiologist or primary care physician he or she should see, how can we get them the information that tells them: what is the cost difference between physicians? How is your choice going to impact your benefit or specific coinsurance or deductible?  How do the providers compare on quality?  What do other consumers think about these providers? There is a lot of work that is still be done in that space.

Real-time Data Access for Prospective Payment Models
In what are the areas your customers are looking to you for in innovating in our field of healthcare data analytics?

When Mr. MaAdoo thinks about what clients are looking for in the future it comes down to three main themes. One is real-time analytics. In today’s environment, the focus is on a retrospective market. There was a bit of a discussion over the past couple of years around it is a prospective model or retrospective model. Clearly the market has adopted the retrospective model for bundled payments and episode-based payment plans.  But ultimately over time, payers will demand more and more real-time access to data, and velocity of data become very important.  Right now, for example, clients are working with paying retrospectively two-quarters data back, and the need is to get closer and closer to real time.  Second, much more integration needs to be done between clinical and claims data. The payer clients rely heavily on claims data. Of course, claims data is tremendous for episodes of care but to get closer to closer to real time having that clinical data is very important. And lastly, predictive analytics is really the future.  Much of what is done now is the getting these payment models set up. However, over time payers are going to want access to information submitted by providers to be able to make predictive analytics around what episodes will occur. So when a patient is admitted for a certain procedure, the projected cost of the full episode is available.  Now information comes from claims data.  Next getting closer to real time and combining it with clinical data is ultimately where payer clients want to move. And lastly, the market is around retrospective payments. The market has adopted a more retrospective model.   It is easier to implement. Payers are paying providers on a fee for service format as they do today and then on the backend retrospectively going up based on risk arrangements that they created with those providers.  We’re starting to see now in the market where many health plans are starting to talk prospectively.  Flag the claim as it gets submitted.  Hold the claim back one payment for the provider.  There are a lot of challenges in the market in the terms of providers paying other providers as well as some other issues, but ultimately that is the direction for the future.

Episodes of Care Education for the Consumer
Robin Gelburd, President, Fair Health:   Having been tasked to do three key things: (1) create a new repository as an information-based for the market, (2) build a free consumer platform that helps consumers in their decision making, and (3) provide data to support policy making and research. Data now resides for 151 million covered lives, making Fair Health the largest private health collection of claims data in the country. With over 20 billion records Fair Health has called upon itself to democratize the data to all its stakeholders.  Ms. Gelburd was excited to announce they are making episodes of care available not just to plans and healthcare systems and consultants, but to bring it down to the consumer level because consumers are really the end users.  She contends if you do episodes right for example like in the Prometheus model  which introduces risk into the budgeting making process, consumers benefit. If you don’t have that type of risk-infused into the model, there may be some difficulty to gain care by some patients because some providers may feel they are not getting a proper budget. Likewise, there can be tremendous confusion on the part of the consumer.  In New York, consumer legislation was recently introduced on the issue of consumers getting “surprise” out of network bills.  For example, a consumer after undergoing a colonoscopy with his gastroenterologist finds out when the bill arrives in the mail.  The bill includes a pathologist and/or an anesthesiologist cost for the additions procedures.  “So again episodes of care and value-based payment really need to be communicated at every single level of the healthcare system. We are excited to do that with our consumer tools,” shared Ms. Gelburd.

This year’s Health Datapalooza was held on May 8 -11, 2016 in Washington, DC and was hosted by AcademyHealth.