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Analytics 101 eBook

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This eBook is designed to take health care professionals a step further than many industry resources have done to date by providing a practical perspective of how analytics are being used to drive …

This eBook is designed to take health care professionals a step further than many industry resources have done to date by providing a practical perspective of how analytics are being used to drive change in health care and in turn driving organizational performance in light of the rapidly evolving health care industry. It begins by providing a common understanding of health care analytics and ends with direction on how to evaluate your own organization and discover what opportunities your organization has to further its competitive edge.

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  • 1. How Market-Leading Health Care Organizations Are Using Analytics to Drive A Competitive EdgeThis eBook is designed to take health care professionals a step further than many industry resources have done to date by providinga practical perspective of how analytics are being used to drive change in health care and in turn driving organizational performancein light of the rapidly evolving health care industry. It begins by providing a common understanding of health care analytics andends with direction on how to evaluate your own organization and discover what opportunities your organization has to further itscompetitive edge.If you have not built the power of these high-value analytic assets into your clinical and financial programs, it is likely that yourorganization is not maximizing the insight that is available to drive your competitive edge.Copyright ©2012 Elsevier, Inc. All rights reserved. Details provided in this document are for information purposes only and, unless specifically agreed to thecontrary by Elsevier in writing, are not part of any order or contract.
  • 2. HOW MARKET-LEADING ORGANIZATIONS ARE USING ANALYTICS TO DRIVE A COMPETITIVE EDGE As the U.S. health care system transitions from a pay-for-service model to pay-for-value through new arrangements including bundled payments and the Accountable Care Organization (ACO), health care organizations require advanced analytics solutions to track, analyze and report on quality and cost across every care setting. Health care services are becoming more patient-centered and are These organizations have a command of their rallying around the themes of accountability, value and collaboration. analytic assets. But more importantly, what is notIn this environment always readily seen by outsiders is that they each Market-leading providers, payers and employers are actively are embedding their analytic assets into these of reform, the committing themselves to one another in an environment of partnership programs rather than using them in boundaries that cooperation and shared success. Together, they are changing their an isolated manner. These activities demonstrate clinical and business processes to achieve results from positive patient that shared analytic assets are increasing shared have traditionally outcomes and efficiency. organizational success. See Figure 1 below: separated health Figure 1: Shared Analytic Assets Support Patient Centered Care care providers, Analytics have been an active part of payers and the health care industry since the 1990s when they were largely financially driven. employers are Providers, payers and employers have changing. each been accessing their analytic data assets to promote their organizational processes and goals. How the analytics have been applied, and the amount of value that has been derived from their use has been up to each organization. Success or failure in driving value from analytic investments has also been up to the individual organization but varies widely across the nation. However, with the increased inter- dependence and focus on sharing of risk that is fostered by health care reform, organizations that have strong data assets and are able to make use of them effectively to drive change will have a very distinct competitive advantage. A health care organization that drives success through predictive analytics is a much more desirable health care partner. 2
  • 3. DEFINING THE TERM “ANALYTICS” The term “analytics” is commonly used in health care, The analytics process/methodology involves accessing but there does not appear to be a single definition of sets of raw data (often created from business and clinical what it truly means within health care organizations. transactions related to patient/provider encounters), and And while we health care analytics experts use the studying them to draw conclusions and gain insights that term and are passionate about the topic as we do were unknown. business, it is necessary to take pause and create clarity. At one end of the spectrum, some use the term These conclusions and insights are not inherently a part A key factor to generically when referring to reporting on data sets. At the other end of the spectrum, some use the term of the raw data. In other words, the transactional process that created the raw data was not specifically designed to remember is that to refer to complex statistical predictions and data mining activities. Both can be correct. support garnering conclusions or insights.the term “analytics” A key factor to remember is that the term “analytics” For the purpose of this text, and at the 50,000-foot level, does not just refer to data but what you do with the datadoes not just refer to health care analytics is a science (methodology) as well and how you change business processes to leverage it. data but what you as a process.do with the data and how you change Highly detailed health care data (such as pharmacy, lab, clinical and business processes A Technical Perspective In health care, analytics frequently 1 payer claims information) are fed into a predictive modeling processing “engine.” to leverage it. involve placing sets of financial The engine conducts a line-by-line review of the large volume of and clinical rules into algorithms that are then built into analytic 2 detailed data. technologies. These technologies The statistical, clinical and financial rules of the engine work to study are able to process an organization’s raw business data to create new, 3 the data, aggregate it and organize it. value-added or enhanced data elements which are then made The engine then creates new “analytic” elements (e.g., Patient Risk available for business or clinical use. 4 Score, Underlying Risk Drivers, Clinical Measures, Forecasted Patient Cost, etc.) that are more useful to clinicians and business professionals Consider the following example of than the highly detailed data could be in their raw state. how an organization transforms large sets of raw, transactional data These new, value-added data elements are then able to be placed into high-value Predictive Analytics: 5 adjacent to the raw data in the database and are made available for clinical and business use. Organizations that are able to make effective us of analytics are at a competitive advantage because they have enhanced insights. However, an organization that has these high-value analytic assets does not have a competitive edge just by having the analytic data. Organizations that are able to enhance their raw data assets are able to be more sophisticated in how they use analytics to guide human decisions or to drive fully-automated decisions. The organization that has a high degree of competitive advantage is one that takes the analytics and then very actively builds these assets into business strategy and operational processes. This leads to a Practical Application perspective of analytics. 3
  • 4. A Practical Application Perspective In health care, the individuals that create analytics are rarely the actual end users of the analytics. If a health care organization creates the analytics internally, it is frequently done by a technology department. It is much more common, however, for health care providers and payers to purchase vendor solutions that will provide pre-packaged analytics. In both instances, business users of analytic information tend to be removed from the technical nature that was discussed earlier in the Technical Perspective. Vendor analytic solutions are typically business intelligence systems that allow end users to analyze and report on the organization’s data as well as the value-added analytic data outputs. The user is less concerned about the technical nature of the analytics and algorithms and is more concerned with how to apply the information to business strategy or operations. For The key to gaining these individuals, the practical perspective of analytics is that they are value-added data elements that are made available within analysis and reporting systems, as shown below in Figure 2: a competitiveadvantage is having these advanced analytics populated in a way where they can be accessed and reported by clinicians and business professionals in theform of alerts, query/ drill-down, ad-hoc reports and standard reports. Source: Image Adapted from Book “Competing on Analytics: The New Science of Winning” by Thomas H. Davenport and Jeanne G. Harris, page 7. Figure 2 illustrates a practical perspective on how predictive modeling is experienced by end users of analytic solutions. Note again that Predictive Modeling is shown as having a high degree of competitive advantage. The key to gaining a competitive advantage is having these advanced analytics populated in a way where they can be accessed and reported by clinicians and business professionals in the form of alerts, query/drill-down, ad-hoc reports and standard reports. Access and reporting are where analytics become linked to business process. 4
  • 5. HOW TO USE PREDICTIVE ANALYTICS TO GAIN A COMPETITIVE ADVANTAGE Predictive analytics are playing a critical role in helping both providers and payers to ramp up their competitiveness and become fortified to survive while the U.S. health care system transforms. This is particularly true for provider organizations that are taking on additional risk for the cost of care while also producing higher quality patient outcomes. Predictive analytics provide a critical, competitive advantage by enabling organizations to have insights that help them to make the most informed decisions possible, given what can be “known” through today’s data. These organizations are very interested to know the: Projected financial risk for individuals as well as sub-populations (i.e., chronic care patients)Predictive analytics Impact of risk on organizational performance against payer/provider contract expectations provide a critical, Types of services that will be required in the upcoming year competitive Individuals who will have higher levels of engagement advantage Individuals who are not in compliance with recommended treatment protocols by enabling Individuals who are most likely to respond well to medical management outreach Individuals who have increased in risk over time organizations to have insights that What Makes the Top Performing Health Care Organizations Different? help them to make Recall from earlier that the key to gaining a competitive More specifically, these top performing health care advantage through Predictive Analytics is having these organizations use analytics to manage risk while improving the most informed advanced analytics populated into analysis and reporting clinical quality, reducing the cost of care and increasing decisions possible, systems that the organization can use to support strategic, efficiency. Organizations that are positioning themselves operational and clinical decisions. Top performing health to lead during this time of change are not only making use given what can be care organizations are highly successful in making use of of their own administrative data assets, but they are also “known” through analytic assets to gain a competitive edge in today’s health care market. While each of these organizations may have making use of data assets that can be obtained through new business relationships that focus on working together today’s data. subtle differences in what they want to accomplish, they to provide quality, value-based care (e.g., Accountable share commonalities in the data they use and how they Care) to patients. However, this is not a simple task. apply it to drive success. They are using it strategically to define their vision, to define their place in the market and Organizations must be able to take the data and make to drive revenue growth by increasing their performance a specific plan on how it will be applied to clinical and against clinical and administrative targets. business activities in order to achieve results. 1 Data assets must be made ready for use. 2 Value must be able to be extracted from the data (Predictive Analytics). 3 Organizations must be able to use analytic data to discover opportunities. 4 Organizations must then go further to define, deliver and measure programs that deliver results based upon use of the analytic data. 5
  • 6. Top Performers Use Analytics to Lever Change Many industry articles discuss the power of health care analytics and work to describe the basics (e.g., Health care Analytics 101). They accomplish a heightened awareness that having a strong analytics platform is no longer a nice-to-have asset, but that analytics are now an operational necessity. However, the challenge with many Analytics 101 articles is that they are not tactical – they stop short of educating executives and analysts on how to directly apply the analytics to business operations in order to achieve the result. All too often these articles do not provide executives with the information necessary to conduct an assessment of their organization’s use of analytics, nor do they provide the information necessary to understand where competitive edge opportunities may exist. In order to leverage analytics in a competitive way in health care, some common questions may be Having an asked to start moving in that direction. advanced ability What do analytics have to do to measure helps Is there a standard method or with the detailed steps of my road map for how top health operational activities? an organization care organizations use analytics? to understand its current state of How will analytics strengthen my relationships with clinicalperformance and set What clinical or administrative and business partners? strategies use analytics? future goals. How will analytic assets impact our business, both from a process and financial perspective? Measure, Manage and Repeat In health care, analytic data elements are particularly good be acceptable. For example, a payer organization that at measuring something in a way that your organization’s uses Predictive Analytics has the ability to focus on the raw data would not be able to accomplish. And they allow Asthmatic population and determine which patients these measures to be applied to a wide array of health care have higher clinical and financial risk. The most effective topics. For example, Predictive Analytics enable a health Predictive Analytics will be able to break this risk down and care provider organization to measure the clinical and show the underlying risk drivers as well as forecast future financial risk of their overall patient population and also issues for the population such as inpatient admissions, further measure the risk for sub-populations such as the re-admissions, emergency room events, etc. patients for a specific clinic, a specific provider or for a specific disease like Diabetes. Analytics are valuable because they measure and bring information to those who are caring for patients – Having an advanced ability to measure helps an information that was not otherwise readily apparent. Once organization to understand its current state of this intelligence is exposed, it can be discussed, and the performance and set future goals. More importantly, an organization can determine what actions, if any, need to organization that has an advanced ability to measure be taken to manage performance and to re-measure and also has the ability to discover specific areas where monitor over time. performance is lower than what is expected or what may 6
  • 7. The Illusion of Control in Health Management After the transition to using analytics in measuring performance is achieved, analytics go on to provide a more significant value in helping organizations conduct the “manage” portion of “measure, manage and repeat.” What does the provider organization that has a diabetic patient population with high financial and clinical risk do about managing that risk? What does the payer organization that has an asthmatic population with a high financial and clinical risk do about managing that risk? What does a large employer do to mitigate the financial impact that high cost cases have on the bottom line of the business? A significant challenge in health care is that organizations cannot control health outcomes – they can only influence them. Organizations Health issues can be treated once they have occurred, they can be avoided through prevention, they can be managed through at the leading edge lifestyle, etc. But at the end of the day, an organization cannot literally control an individual or population’s health outcome. Yet organizations must deal with repercussions (often financial) of health outcomes. In light of this challenge, organizations have learned how at the leading edge have learned how to use analytics to influence those outcomes better than their competitors do. These to use analytics health care organizations understand the art of influence and use the advanced insights that analytics provide to drive the “levers” that are available to them – the activities that they can do to incent, steer or guide change to occur. to influence thoseoutcomes better than Examples of Levers that EMPLOYERS Use Examples of Levers that PAYERS Use totheir competitors do. to Influence Health Care Quality and Cost Influence Health Care Quality and Cost BENEFITS OFFERINGS UNDERWRITING AND Employers can determine if they will offer benefits, at INTERNAL RISK what point in time an employee becomes eligible for Payers actively manage risk through underwriting benefits, which benefits to offer various sub-populations, processes and use actuaries to manage risk for the how to structure benefits for populations and where in organization with estimates of “future” expenses. those populations they can most effectively shift costs to employees via deductibles, coinsurance and copay. HEALTH AND WELLNESS Payers can offer health/wellness programs, disease HEALTH AND WELLNESS management and health risk assessment programs to Employers can offer health/wellness programs, disease populations that may most benefit from participation or management and health risk assessment programs to may be at higher levels of financial or clinical risk. employees that meet certain criteria. And they can highly incent participation via benefit design. NETWORK DESIGNS AND NETWORK-FOCUSED PRODUCTS RISK ARRANGEMENTS WITH PAYERS Payers can offer pre-defined provider networks and can Employers can better anticipate financial risk when work to actively improve the depth, breadth and quality negotiating coverage arrangements with payers when of provider networks. Payers can also increase levels of decisions are informed by the enrolled population’s clinical and financial accountability with providers related overall risk, underlying drivers, motivation toward wellness to the care they deliver. and healthy lifestyles, etc. 7
  • 8. Examples of Levers that PROVIDER ORGANIZATIONS Use to Influence Health Care Quality and Cost RISK ARRANGEMENTS WITH PAYERS Providers can collaborate with payers through new risk- and-reward reimbursement arrangements that center on themes of Accountable Care and Value-based Care, as well as collaborate in partnership programs that work to Clinical and increase quality and efficiency. business activity “levers” are more CARE DELIVERY PROCESS Providers can improve the processes used to deliverpowerful when they care to gain efficiency, improve the level of quality and improve patient satisfaction and engagement are based upon analytic insights. PATIENT OUTCOMES Providers can improve the measurement and management of patient outcomes according to standards of care defined by the medical industry. Moreover, provider organizations can evaluate practice pattern variances in light of outcomes and work to bring consistency to system-wide care delivery. COST MANAGEMENT Providers can gain internal efficiencies by analyzing cost and utilization patterns and understanding established benchmarks, including how they measure against them. Using these insights to change care delivery is key to be- coming more competitive. HEALTH AND WELLNESS Providers can collaborate with health/wellness programs, disease management and health risk assessment programs for patients and employers. Using these programs to identify opportunities for intervention or stronger population management is key to influencing outcomes. These clinical and business activity “levers” are more powerful when they are based upon analytic insights. Advanced insight guides strategy work by highlighting unseen opportunities while also illuminating underlying patterns that may need to be addressed. Advanced insight guides operational work by helping to hit the target more accurately, address challenges associated with underlying drivers and help to sophisticate an organization’s ability to prioritize. 8
  • 9. KEY CONSIDERATIONS There is a traditional, competitive advantage in making Organizations that own analytic data assets and go the strong use of analytics to drive your organization’s internal distance to actively share these assets through cooperative performance. But in the rapidly evolving health care programs will have a distinct competitive advantage over market, it has become clear that an organization’s success those that do not use information as strategically. is increasingly dependent on the ability to become a more desirable clinical and business partner by sharing the As your organization creates a strategy for success in power of analytic assets and using them in partnership this environment, keep in mind that analytic assets programs. are escalating in value. Market leading health careAnalytics help define Health care reform is fostering new levels of organizations have analytics represented on their strategic road maps – directly (and most importantly) as key driversa program’s strategy cooperation and is increasing the shared financial risk of operational programs. They have them, and are building between health care providers, payers and employers. them into how they do business. and are also used within operational We invite you to actively investigate your own health care steps of programs. organization by considering the following method: 1 Look to see if the data that guides that itorganization’s strategies is maximized – meaning your relies heavily 2 See if your operational programs (Patient Health Improvement, Cost/Risk Management, Efficiency, on the power of advanced health care analytics Quality, Performance Management, etc.) are built (including predictive analytics) rather than relying using advanced analytics that are avilable to optimize solely on aggregations of raw operational data. each program for success. Compare the analytic assets used in your opera- 3 Spend some time scratchingprograms and find out of your operational business beneath the surface 4 tional programs to industry best practices as well exactly which analytic data elements are being as what market leaders use to drive their programs utilized. If analytics are not driving your programs, (examples noted earlier). If your programs are not it is a red flag that your organization is not using the built with the depth and breadth of market-leading insight that is available to drive your competitive analytics, it is an indicator that your organization has edge. opportunities to further its competitive edge. The appendix that follows is designed to support your investigation by sharing our industry expertise. In these pages, we highlight the types of programs that you may wish to evaluate – programs that are likely operating across various departments within your organization. More importantly, this appendix will point out the types of analytics that market- leading organizations are using within their programs along with a description of what each analytic provides. From our unique vantage point, we can see best practices and market-changing activities, and our goal is to share our knowledge so that your organization can benefit from what we see. Leading edge organizations have a command of the levers that are available to them, and they have a command of their analytic assets. They achieve success by building advanced analytics into their clinical and business programs, which operate to lever the desired outcome. Analytics help define a program’s strategy and are also used within operational steps of programs. While the industry uses a wide array of programs, they generally fall into five categories. Within each of these five categories, there are a number of key analytic assets that are being used to drive their success. 9
  • 10. Primary Focus #1 The primary focus of these programs is to improve the health of patients/members. With these programs the organization is saying, “I want to improve the health of my patient/member population because healthy people have a higher quality of life and cost the system less.” DISEASE MANAGEMENT Targets specific diseases or medical conditions, typically chronic diseases such Examples of as Diabetes, Asthma, Hypertension, Heart Failure, etc. Patient Health PREVENTIVE CARE PATIENT Improvement Programs Focuses on making sure that people are getting the routine medical care necessary to proactively manage and monitor health WELLNESS HEALTH Ensures maintenance of healthy lifestyles, exercise and eating habitsIMPROVEMENT Examples of Analytics Used in Patient Health Improvement Programs PROGRAMS EPISODES OF CARE Provides as complete a picture as possible of a disease or medical condition for a single patient/member or a population and includes inpatient, outpatient, professional and pharmacy services. Episodes of Care are frequently used to analyze the cost patterns, service patterns or provider practice patterns underneath specific diseases or medical conditions, and are excellent at supporting the analysis needed for patient health improvement programs. FORECASTED RISK INDEX Provides an index number for a patient/member that describes the relative risk the patient/member has (for utilizing services and incurring cost) when compared to the population. Risk indices are frequently used to prioritize lists of patients/members in patient health improvement programs. RISK DRIVERS Describes the underlying risk factor(s) that drove the patient/member’s risk forecast. Health improvement programs can use Risk Driver information to provide additional insights to consider when planning resources to include in health improvement programs. RISK CATEGORY Provides an easy-to-use categorization of the level of risk for patients/ members (e.g., 1 = Well, 2 = Low, 3 = Medium, 4 = High Risk and 5 = Catastrophic). Risk categories help to prioritize lists of patients/members with- APPENDIX: How to Apply in a patient health improvement program and can also be used to highlight Predictive Analytics to Clinical sub-populations that may have differing needs for program resources. and Business Processes 10
  • 11. FORECASTED INPATIENT DAYS #1 cont’d. Forecasts the number of days a patient/member will have in an inpatient facility in the next 12 months. This forecast information provides insight into which patients/ members may have need for program resources that work to eliminate an inpatient admission, reduce the length of stay or reduce the intensity of inpatient services. PATIENT HEALTH FORECASTED EMERGENCY ROOM (ER) VISITS IMPROVEMENT Forecasts the number of ER visits a patient/member will have in the next 12 months. This forecast information provides insight into which patients/members may have need PROGRAMS for program resources that work to eliminate or reduce the need for ER services. GAPS IN CARE Flags patients/members that are non-compliant with evidence-based guidelines of care – guidelines that have been created by the medical community that describe quality of care requirements for specific diseases, medical conditions or preventive age/gender demographics. Gaps in Care are excellent for use in patient health im- provement programs because they provide specific information about the treatment protocols the individual has not received. CHRONIC IMPACT SCORE Provides a score (0-100) that forecasts the patient/member’s propensity for chronic Gaps in Care to be impactable. Patient health improvement programs can use this analytic to channel resources to individuals that have a higher potential for increasing their compliance with recommended treatment protocols. ACUTE IMPACT SCORE Provides a score (0-100) that forecasts the patient/member’s propensity for acute utilization to be impactable. Patient health improvement programs can use this analytic to channel resources to individuals that have a higher potential for being medically managed to reduce their utilization of services and cost. MOTIVATION RANK Provides a score (0-100) that forecasts the patient/member’s level of motivation to engage with physicians and self-manage. Patient health improvement programs can use this analytic to channel resources to individuals that have a higher likelihood to engage with the care delivery system and comply with treatment programs. MOVER MEMBERS Indicates the patient/member has increased or decreased in risk since the last time that risk was measured. Patient health improvement programs can use this to channel program resources to individuals increasing in risk, and see where program resources may intercede and provide support. Patient health programs can identify APPENDIX: How to Apply individuals who are decreasing in risk, which may assist in modifying the type orPredictive Analytics to Clinical intensity of resources for those individuals. and Business Processes 11
  • 12. Primary Focus #2 The primary focus of these programs is to manage the overall cost and the financial risk associated with providing health care services to patients/members. With these programs the organization is saying “I want to manage financial impact that providing these services has on my organization’s budget as well as manage the financial risk associated with my organization’s survival.” BENEFIT DESIGNS Creates benefit packages for an employer’s employee population that work to strike a healthy balance between robust coverage and cost containment NETWORK UTILIZATION/LEAKAGE COST/RISK Channels patients to specific health care providers within a desired network Examples ER UTILIZATION of Cost/Risk Uses the ER for only emergency conditions, delivering care efficiently within the ERMANAGEMENT Management Programs THE IMPACT OF CODING Focuses on the impact of coding on reimbursement and organization performance PROGRAMS CASE MANAGEMENT Programs that focus on managing complex and/or costly medical cases UTILIZATION MANAGEMENT Programs that focus on specific utilization patterns of concern, such as high-cost diagnostic imaging services, knee replacement services, gastric bypass services, etc Examples of Analytics Used in Cost/Risk Management Programs EPISODES OF CARE FORECASTED MEDICAL COST Provides as complete a picture as possible of a disease Forecasts a patient/member’s cost for medical services or medical condition for a single patient/member or a for the next 12 months based on previous 12 months’ population and includes inpatient, outpatient, professional data. Cost/risk management programs can use this to and pharmacy services. Can be used to illustrate cost, inform program activities that target medical cost or service and provider practice patterns and are an excellent utilization of medical services for specific populations. tool for analyzing potential savings opportunities. FORECASTED DRUG (RX) COST FORECASTED RISK INDEX Forecasts a patient/member’s cost for pharmacy services An index number for a patient/member that describes for the next 12 months based on previous 12 months’ relative risk (for utilizing services and incurring cost) data. Cost/risk management programs can use this to compared to the population. Indices for groups can be inform program activities that target pharmacy costs or shown at an aggregate level. Cost/risk management utilization of pharmacy services for specific populations. programs use aggregated risk indices to compare risk for sub-populations of interest. MOVER MEMBERS RISK DRIVERS Indicates the patient/member has increased or decreased Describes the underlying factor(s) that drove the patient/ in risk since the last time that risk was measured. Cost/ member’s risk forecast. Risk drivers for groups are shown at risk management programs can use this analytic to quickly an aggregate level. Cost/risk management programs study identify sub-populations that have a shift in risk, and then APPENDIX: How to Apply underlying risk drivers to understand a specific population study the group(s) in order to gain insight on underlying Predictive Analytics to Clinical and/or compare risk drivers for sub-populations of interest. trends within these populations. and Business Processes 12
  • 13. Primary Focus #3 The primary focus of these programs is to identify and fix inefficiencies associated with delivering care. With these programs the organization is saying “I want to drive more efficiency into the care that is provided so that my patients/members receive the right services, at the right time, in the optimal environment and with the most efficient use of financial resources.” PROVIDER PERFORMANCE Analyzes provider practice patterns to discover opportunities to increase quality, to become more cost effective or to manage performance compared to Examples organizational targets EFFICIENT of Efficient Health Care PATIENT-CENTERED CARE/MEDICAL HOME Focuses on medical management and rewarding quality patient-centered care HEALTH CARE Resource Consumption ACCESS TO CARE Ensures that patients/members have adequate access to care based upon geography, service type, diseases/medical conditions, etc RESOURCE Programs NETWORK COVERAGE Ensures that provider networks contain a mix of provider types and service offeringsCONSUMPTION that fulfill the needs of the patient/member population PROGRAMS Examples of Analytics Used in Efficient Health Care Resource Consumption Programs EPISODES OF CARE Provides as complete a picture as possible of a medical condition for a single patient/member or a population and includes inpatient, outpatient, professional or pharmacy services. Frequently used to analyze service or provider practice patterns underneath specific medical conditions. They are often used to identify variation from expected norms and support further drilling to discover potential opportunities to gain efficiency. FORECASTED RISK INDEX An index number for a patient/member that describes relative risk (for utilizing services and incurring cost) compared to the population. A higher risk index suggests that the patient/member is forecasted to have a higher utilization of future services, and may benefit from MOTIVATION RANK program intervention. A score (0-100) that forecasts the patient/ member’s level of motivation to engage with physicians and self-manage. Efficiency programs ACUTE IMPACT SCORE can use this analytic to identify patients/ A score (0-100) that forecasts the patient/member’s propensity for members that have a higher likelihood to engage acute utilization to be impactable. Efficiency programs can use this with the care delivery system and comply with APPENDIX: How to Apply analytic to identify patients/members with a higher potential for efficiencies that are built into treatment programs Predictive Analytics to Clinical being medically managed to reduce their utilization of services for their disease or medical condition. and Business Processes 13
  • 14. Primary Focus #4 The primary focus of these programs is to identify and improve known quality issues that are high profile targets within the health care system. With these programs the organization is saying “I want to ensure that I’m doing all that I can to address these important topics within my industry.” Examples include reducing re-admissions, increasing patient-centeredness, medication management programs, etc. RE-ADMISSIONS Focuses on patients/members that are re-admitted to an inpatient facility after having a previous discharge (for the same condition or for any condition) DISEASE MANAGEMENT QUALITY Examples of Quality Focuses on specific diseases or medical conditions, typically chronic diseases such as Diabetes, Asthmas, Hypertension, Heart Failure, etc.MANAGEMENT PATIENT-CENTERED CARE/MEDICAL HOME Management Focuses on programs that focus on medical management and rewarding quality Programs patient-centered care PROGRAMS MEDICATION MANAGEMENT Ensures that patients/members are complying with their medication regimen and manages the complications of drug interactions if they are on more than one drug Examples of Analytics Used in Quality Management Programs GAPS IN CARE Flags patients/members that are non-compliant with evidence-based guidelines of care – guidelines created by the medical community that describe the quality of care requirements for specific diseases, medical conditions or preventive age/gender demographics. Gaps in Care are excellent for use in quality improvement programs because they provide specific information about the treatment protocols the individual has not received. Closing these gaps improves quality. EPISODES OF CARE Provides as complete a picture as possible of a disease or medical condition for a single patient/member or a population and includes inpatient, outpatient, professional and pharmacy services. Episodes of Care are frequently used to analyze service patterns or provider practice patterns underneath specific diseases or medical conditions and are excellent at supporting the analysis needed for quality improvement programs. CHRONIC IMPACT SCORE An analytics that provides a score (0-100) that forecasts the patient/member’s propensity for chronic Gaps in Care to be impactable. Quality management programs can use this to channel resources to individuals who have higher potential for increasing compliance with recommended treatment protocols. ACUTE IMPACT SCORE A score (0-100) that forecasts the patient/member’s propensity for acute utilization to be impactable. Quality management programs can use this to channel resources to individuals with higher potential for being medically managed. MOTIVATION RANK APPENDIX: How to Apply A score (0-100) that forecasts the patient/member’s level of motivation to engage with physicians and self-manage. Quality Predictive Analytics to Clinical management programs can use this analytic to channel resources to individuals with a higher likelihood to engage with the and Business Processes care delivery system and comply with treatment programs. 14
  • 15. Primary Focus #5 The primary focus of these programs is to demonstrate an organization’s performance and improvement. With these programs, the organization is saying “I want to measure performance, identify opportunities for improvement, implement operational programs to address the opportunities and then demonstrate improvement.” ORGANIZATIONAL PERFORMANCE Examples of Focuses on improving an organization’s performance measures of quality, cost, patient/member satisfaction, etc. PerformancePERFORMANCE Management PROVIDER PERFORMANCE Analyzes the practice patterns of individual physicians or facilities to discover Programs opportunities to increase quality, to become more cost effective or to manageMANAGEMENT performance compared to organizational targets PROGRAMS Examples of Analytics Used in Performance Management Programs GAPS IN CARE Flags patients/members that are non-compliant with evidence-based guidelines of care – guidelines created by the medical community that describe the quality of care requirements for specific diseases, medical conditions or preventive age/ gender demographics. Gaps in Care are an artifact of the quality measurement process, which is specifically designed to measure performance against care standards. EPISODES OF CARE Provides as complete a picture as possible of a disease or medical condition for a single patient/member or a population and includes inpatient, outpatient, professional and pharmacy services. Episodes of Care are frequently used to discover performance improvement opportunities related to cost of services, efficiency in service utilization or potential quality concerns. FORECASTED RISK INDEX An index number for a patient/member that describes the relative risk the patient/member has (for utilizing services and incurring cost) when compared to the population. The risk burden of a patient/member population is an important APPENDIX: How to Apply consideration in performance improvement programs, and it is a standard Predictive Analytics to Clinical component built into the equations that calculate performance. and Business Processes 15
  • 16. 4901 Vineland Road Suite 450 Orlando, FL 32811 866.422.5156 www.medai.comCopyright ©2012 Elsevier, Inc. All rights reserved. Details provided in this document are for information purposes only and, unless specifically agreed to thecontrary by Elsevier in writing, are not part of any order or contract.

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