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    Eng Eng Presentation Transcript

    • DTEC ™ IMPROVING THE QUALITY OF CARE THROUGH CLAIMS DATA ANALYSIS Benjamin Eng, MD, MA AHQA 2005 Fall Meeting Quality Measurement and Improvement in the New Medicare Prescription Drug Benefit November 17, 2005 Washington, D.C.
    • AGENDA s Introduction s What is DTEC™? s DTEC™ Reports s Examples from test sites s Potential Part D implications and applications © Pfizer Inc. All rights reserved
    • CHALLENGES FACING HEALTHCARE TODAY Many Organizations Face Challenges in Identifying Gaps in the Quality of Care for Patient Populations © Pfizer Inc. All rights reserved
    • ™ DTEC Supports the Quality Improvement Process Assess Baseline Performance Identify Barriers for Intervention Target Individuals for Intervention Design and Implement Intervention Reassess Performance Periodically © Pfizer Inc. All rights reserved
    • ™ DTEC Supports the Quality Improvement Process Assess Baseline Performance Identify Barriers for Intervention Target Individuals for Intervention Design and Implement Intervention Reassess Performance Periodically © Pfizer Inc. All rights reserved
    • WHAT IS DTEC™? s DTEC is a service offered by Pfizer that: • Uses the customer’s claims data to identify their member populations with targeted diseases – First module covers CV diseases (hyperlipidemia, hypertension, diabetes, ischemic heart disease, congestive heart failure) • Produces aggregate and member-specific reports • Provides analysis of the aggregate reports s DTEC is HIPAA-compliant because no member-specific data leaves the customer or is viewed by Pfizer © Pfizer Inc. All rights reserved
    • DTEC™ BENEFITS s DTEC • Lowers the barriers to improving the quality of care members receive • Leverages existing data resources to develop reports that facilitate use of appropriate interventions for targeted groups of members © Pfizer Inc. All rights reserved
    • DATA FIELDS UTILIZED BY DTEC™ SOFTWARE Professional Services Information Drug Utilization Information s Member ID s NDC Number s Claim Number s Member ID s Claim Line Number s Prescription ID s From Service Date s Date Filled s To Service Date s Days Supplied s Procedure Code s Quantity s Principal Diagnosis Analyzed s Additional Diagnoses (4) Over Time s Place of Service Enrollment Information Facility Services Information s Member ID s Member ID s PCP ID s Claim Number s Member Gender s Claim Line Number s Year of Birth s From Date EMERGENCY s Effective Date s To Date s Termination Date s Principal Diagnosis s Additional Diagnoses (4) s Place of Service © Pfizer Inc. All rights reserved
    • DTEC™ SUMMARY DATABASE Claims and Enrollment Data Data for Population (4 files) Continuous Enrollment DTEC Software Disease Identification Summary Dataset s Demographics Demographics s Patterns Co-morbidities Complications s Care Improvement Utilization Quality Gaps © Pfizer Inc. All rights reserved
    • DTEC™ PATIENT IDENTIFICATION s Levels of confidence for identifying members with each targeted disease • Lenient, Normal and Strict s Stratifications of disease severity • Usual, Moderate and High © Pfizer Inc. All rights reserved
    • CONFIDENCE LEVELS FOR DISEASE IDENTIFICATION ARE INCLUSIVE (LENIENT INCLUDES MEMBERS CATEGORIZED AS NORMAL AND STRICT) Lenient Normal Strict © Pfizer Inc. All rights reserved
    • EXAMPLE: DTEC™ CRITERIA FOR IDENTIFYING MEMBERS WITH HYPERLIPIDEMIA Minimum Number of Claims Needed Criteria Lenient Normal Strict Hospitalization with Diagnosis or 1 1 1 Diagnosis on Professional Claims with Different Dates of Service or 1 3 4 Rx for Lipid Lowering Agent or 1 2 4 Diagnosis on Professional Claims and Rx for Lipid Lowering Agent NA 1/1 3/1 © Pfizer Inc. All rights reserved
    • PERCENT OF MEMBERS IN COMMERCIAL HEALTH PLAN POPULATION IDENTIFIED BY DTEC™ AS HAVING CV DISEASE 25% 16% 14% 5% 4% DM Hyperlipid HTN IHD Any CVDs Lenient Normal Strict Data on file for 100,000 member commercial health plan Note: The Lenient category includes members classified as Normal and Strict © Pfizer Inc. All rights reserved
    • DTEC™ SOFTWARE PROCESS Raw Claims Data (4 Files) DTEC Phase 1 Data Audit and Summary Summary Access Database (in DTEC) DTEC Phase 2 Query Database Demographic Utilization Clinical Care Improvement Reports Reports Reports Reports Patient Drill Down © Pfizer Inc. All rights reserved
    • DTEC™ REPORTS DTEC Reports CHF Added Summary Report Hypertension Hyperlipidemia Ischemic Heart Diabetes Disease 6 Reports 6 Reports 6 Reports 6 Reports 1 Care Imp. Report 1 Care Imp. Report 1 Care Imp. Report 1 Care Imp. Report © Pfizer Inc. All rights reserved
    • DTEC™ AGGREGATE DISEASE POPULATION REPORTS s Disease prevalence by level of confidence s Demographics by disease severity s Comorbidities and complications (2 reports) s Hospitalizations, ER visits and medical services received s Medications / medication compliance (2 reports) s Care Improvement reports © Pfizer Inc. All rights reserved
    • CARE IMPROVEMENT REPORTS DTEC™ uses specific predefined criteria, called care improvement algorithms, that identify populations with opportunities to improve the quality of care s Aggregate reports show the percentage of the disease population meeting the care improvement algorithm criteria s Member specific targeting reports “drill down” and produce lists of individual members for possible intervention © Pfizer Inc. All rights reserved
    • Sample Claims Based Quality Inferences Heart Failure Diabetes s No renal function testing s No HbA1c test s No lipid profile s No lipid profile s No cholesterol test after s No renal function testing hospitalization s No urine protein test s Thiazide or loop diuretic, no s No eye examination potassium check s No follow up visit within 45 s ACE or ARB treatment days of hospitalization s No follow up visit within 45 s Fewer than 2 visits during days of discharge reporting period © Pfizer Inc. All rights reserved
    • Intervention Decision Making Belongs in the Hands of the Clinician DTEC Reports CHF Added Summary Report Hypertension Hyperlipidemia Ischemic Heart Diabetes Disease 6 Reports 6 Reports 6 Reports 6 Reports 1 Care Imp. Report 1 Care Imp. Report 1 Care Imp. Report 1 Care Imp. Report 1 Patient CI Report 1 Patient CI Report 1 Patient CI Report 1 Patient CI Report Patient Detail Report CI – Care Improvement © Pfizer Inc. All rights reserved
    • EXAMPLES OF DTEC™ DATA SUMMARIES FROM THE TEST SITES © Pfizer Inc. All rights reserved
    • PREVALENCE OF CARDIOVASCULAR DISEASES COMPARED TO BENCHMARK DATA Percent of Members with CVD 35% 16% 16% 15% 10% 4% 5% 3% DM Hyperlipid HTN IHD MCO Benchmark (NHANES III) Data on file for 200,000 member combined commercial and Medicare health plans © Pfizer Inc. All rights reserved
    • CLASSIFICATION OF MEMBERS WITH DIABETES BY SEVERITY (N=5,629) Usual 44% 43% Moderate 13% Severe Data on file for 200,000 member combined commercial and Medicare health plans © Pfizer Inc. All rights reserved
    • DIABETES COMORBIDITIES Percent of Members with Diabetes 51% 36% 22% 11% 11% 4% 3% Hyperlipidemia Ischemic HD Cerebrovascular Dis Acute MI Hypertension CHF Obesity Data on file for 200,000 member combined commercial and Medicare health plans © Pfizer Inc. All rights reserved
    • COMPLICATIONS IN MEMBERS WITH DIABETES Percent of Members 15% 10% 8% 7% 3% 1% 1% Hypoglycemia Kidney Skin UTI Visual Other Peripheral Failure Ulcer Loss Eye Neuropathy Data on file for 200,000 member combined commercial and Medicare health plans © Pfizer Inc. All rights reserved
    • CARE IMPROVEMENT OPPORTUNITIES IN MEMBERS WITH DIABETES Percent of Members 41% 29% 28% 23% 12% 13% 9% No HbA1c No Eye No Lipid w/HTN, w/↑Chol, No Hosp F/U <2 Visits/ Exam Profile No ACEI No Statin Year or βB Data on file for 200,000 member combined commercial and Medicare health plans © Pfizer Inc. All rights reserved
    • EXPERIENCE WITH DTEC™ SERVICE s Implemented with nearly 20 health plans • Includes 2 Medicare Advantage plans s Purpose of DTEC implementation has included • To measure baseline CV assessment data • To determine whether to start a CV quality initiative • To identify patients for a  case management quality improvement program • To identify patients for a pilot Diabetes intervention program      • To identify patients for a patient CV education program • To document quality trends over multiple years • To identify a population of high risk patients to conduct an adherence study on © Pfizer Inc. All rights reserved
    • Unique Features of DTEC’s Design s Data audit and integration is automated after data input files are properly formatted s Summary dataset is retained while individual claims are processed and discarded s Pre-defined reports are based on the summary dataset, transferring analysis to the desktop s Population level reporting is linked to member level drill down reports for targeting interventions s Clinician level review of drill down patient lists is supported to verify quality improvement insights © Pfizer Inc. All rights reserved
    • Possible Implications for QIOs and Medicare Part D Quality s Claims data can provide insight into the quality of care for beneficiaries s The resource burden to integrate and analyze A, B, D and administrative claims data can be dramatically lowered leveraging this type of technology s Similar tools can place analytic power and targeting capabilities in the hands of Quality Improvement Organizations to work with Medicare providers s Data analytics can only support clinical decision making. Clinical decision making belongs in the hands of the clinician. © Pfizer Inc. All rights reserved