More healthcare organizations than ever are embarking on value-based payment programs, such as the Medicare Shared Savings Program and commercial accountable care organization initiatives. These program participants are discovering that efficiently managing populations of patients, especially high-risk patients, is essential to earning enhanced revenue and controlling costs.
Unfortunately, the data analysis used to manage these populations across the care continuum, detect care gaps and initiate interventions is usually based on claims data that could be as old as 120 days.
For more timely analysis, many organizations are leveraging their own electronic health record data. This data, even within integrated organizations, is difficult to aggregate because it is often captured with different documentation methods or is locked away in incompatible EHR systems. Even when patient data is harmonized into a single record, it does not provide critical insights into claims-related data, such as hospital costs, or which patients are receiving care elsewhere, and why.
To overcome these obstacles to program success, organizations need tools that will seamlessly combine clinical, claims, PBM and lab data so providers can identify high-risk patients, pursue corrective action before an adverse event occurs and deliver trustworthy performance reports to physicians, all in real time.
Combining data continues to challenge organizations
While many integrated organizations are linked by a single EHR system, data that could be leveraged for population health management may be represented differently depending on physician or facility. For example, one physician may check a box in a chart to indicate he counseled a patient on smoking cessation, a required quality metric under the MSSP, while another may enter a procedure code for the same action.
Therefore, when ACOs and other integrated organizations try to analyze data about smoking cessation, the reports generated may only include the patients whose physicians’ EHR software uses a checkmark. Harmonizing that data entry so that all activity is accurately captured can be a challenge without the right warehousing tools.
This challenge is magnified when the data capture and analysis must be extended to practices or hospitals that are unaffiliated with the ACO. These organizations’ data must also be included in the clinical quality and cost data analysis, which requires compiling payer-supplier claims information into the data warehouse.
When reports are based on data that comes only from payers physicians may be skeptical of the accuracy, especially when reports reflect poorly on their clinical performance. To establish greater credibility, organizations need tools that create quality performance reports that can be easily verified for accuracy against physicians’ own charts and claims. Once greater trust is established, reports are met with less resistance and behavior-change discussions can be more collaborative.
New technologies yielding better population management processes
Many organizations that just completed, or are still going through, a major EHR implementation, may not be aware of the newer population health management technologies available that can support their existing systems. These tools can capture claims and clinical data, normalize the information, eliminate duplicate entries, and run analytics automatically or on-demand. Based in the cloud, the newer population health management tools can be setup to analyze data with little or no impact on existing IT staff.
The reporting available on these tools can be viewed as real-time dashboards or as trustworthy quality performance reports. Because organizations monitor different metrics depending on the accountable care program or patient population, the dashboards can be configured to automatically deliver updates about any number of care quality or risk indicators, which encourages more timely and effective interventions.
A population health management tool integrating an entire organization also relieves providers from calling physician offices to have them fax patient chart documentation. This will reduce phone calls and the need to abstract paper charts and allow care coordinators to focus on identifying and intervening with high-risk patients.
The tools also allow providers to identify anomalies in ways that are not feasible with most current tools. For example, an ACO and MSSP participant in North Texas utilizing an enterprise-wide population health management tool that combines claims and clinical data found that a patient had been prescribed a monthly back pain injection by an unaffiliated physician at a cost of $16,000 per treatment.
The patient’s affiliated provider was able to see the cost data at the point of care and discovered from the patient that the injections were yielding little benefit. The injections were replaced by a $40-a-month oral medication and the patient’s symptoms improved. Without access to that information, the provider might not have questioned the patient or intervened with an alternative treatment plan.
Value-based payment requires visibility beyond the exam room
With value-based payment programs and penalties for preventable hospital readmissions, providers are recognizing the need to monitor their patients’ chronic conditions throughout the care continuum and intervene before costly emergency department visits or hospitalizations occur. By capturing, combining and harmonizing available clinical and claims data, organizations can generate a more accurate, timely and comprehensive view of a single patient, or of thousands.
Better quality data leads to more cost-effective interventions and better outcomes—and better outcomes are what value-based payment models are all about.
