Analytics in Healthcare

1. BIG DATA IN
HEALTHCARE
Nondas Sourlas
Director, Bupa Healthcare Analytics
27 October 2016

2. Bupa Private and Confidential
Bupa – British United Provident Association
• Global healthcare company with Healthcare Provision and Private Medical Insurance:
― Australia, Chile, India, New Zealand, Poland, Saudi Arabia, Spain, UK
― 336 clinics, 565 dental centres, 17 hospitals, 453 care homes, 36 optical centres, and
60 retirement villages
• 84,000 people who support our 32 million customers in 190 countries around the world
generating £9.8bn revenue in 2015
• UK’s largest private medical insurance company
• No shareholders; reinvesting profit
2

3. Bupa Private and Confidential
Analytics in Healthcare
CARE PAYMENT
• products, marketing and sales
• medical coverage & health risk
management
• client services and reporting
• actuarial forecasting
CARE DELIVERY
• secondary care, medical and surgical
• nursing and residential, continuing
healthcare and discharge to assess
• intermediate care and rehabilitation
services
• multidisciplinary care in the community
REMOTE CLINICAL
AND ADVISORY
SERVICES
• health coaching
• support lines and health
information
• patient support programmes
HEALTHCARE
ANALYTICS
• population analytics and risk
stratification
• commissioning & provisioning
opportunity analysis
• service evaluation & patient
outcomes
• fraud detection & prevention
COORDINATION
OF SERVICES
• patient assessment &
care planning
• pathway management &
case management

4. Bupa Private and Confidential
Healthcare Risk
HRM should
support and
inform:
• Product/service
design and
development (inclu. for
funding, provision,
integrated care and
digital businesses)
• Sales
• Marketing
• Claims processing
• Ect.
27 November 2013 4
HEALTH RISK MANAGEMENT
Analytics, Data
Quality and Coding
Contracting and
Demanding
Management
Quality and Care
Management
Claims Leakage
and Fraud
Management
HRM is the insight, action and response taken as a result
of the combined management and utilisation of these core
interdependent capabilities, along with others, to:
• Manage the benefits cost line
• Deliver the most appropriate care (right place, right
time, right intervention)

5. Bupa Private and Confidential
Outcomes
&
Value
Case Study 1: Risk Modelling & Care Management
5
• Shared Decision Making
• Top conditions coached – MSK, Cardiovascular, Oncology
and Post Surgical Support
• Health Coordinator using appropriate points of referral for a
complete care pathway support
“No decision
about me
without me”
• Predictive modelling and risk stratification to identify and
prioritize members in need
• Targeted telephonic outreach using a combination of
predictive analytics and clinical pathway identification
• Analysis & Evaluation using population risk adjustment
Predictive
Analytics
& Evaluation
21 January 2015
• Member Feedback: 79% extremely or very satisfied with
the service
• Annualized, the programme has shown a reduction of:
• Over 1,500 outpatient visits
• over 1,500 diagnostic tests
• 100+ surgical procedures
• 9-10% savings in the cost of care of engaged
members

6. Bupa Private and Confidential
Case Study 2: Consultant Profiling & Referral Management
6
• We use clinical information and statistical case mix adjusting
methods in profiling consultants
• In total, 20 provider specialties have been profiled, classifying
almost 18k preferred and non-preferred consultants.
• Since Open Referral, more than 700k pre-authorisations
have been guided
• In December 2014, the percentage of pre-authorisations
guided stood at 12%
• 80% of our Corporate clients are on the Open Referral
product
• Estimated healthcare savings PTD stand at 9-11% of guided
healthcare spend
• We have created client reporting for the Open Referral product
• Use claims and quality data to risk profile consultants.
• Referrals are guided based on insights derived from our data
through cutting edge analytics based on clinical practice and
efficiency

7. CASE STUDIES

8. RISK MODELLING
&
CARE MANAGEMENT

9. Bupa Private and Confidential
Care management & Member’s Risk
9
Case
Management
Condition
Management &
SDM
Supported Self-care
Management
Prevention & Wellness
Promotion
Engage proactively with the highest risk members, at the right time, through the right channel
with the right support programme to optimize clinical, financial and satisfaction outcomes
PredictedRisk
Case Management
Condition Management
& SDM
Supported Self-
care Management
Prevention &
Wellness
Promotion
Claims Spend
Population

10. Bupa Private and Confidential
Condition Management & SDM
10
Key features
• Condition management & SDM delivers
telephonic member outreach and tailored
support.
• Members identified in the top 90th– 99th
percentile of predicted claims spend, account
for ~40% of total claims spend
Desired outcomes
• Improvement of health outcomes and experience of members with complex
care needs.
• Preventing unnecessary healthcare use and avoiding adverse events due to
uncoordinated healthcare delivery.

11. Bupa Private and Confidential
Challenges and approaches
11
Learning from
previous work
Improved
data inputs
Flexibility in
predictions
Ensemble
modelling
Performance
analyses
Resource
allocation
Understanding
the data

12. Bupa Private and Confidential
Data structuring
12
Pre-authorisation Data Variables
For a subset of treatment areas, a measure of “time since last
occurrence” are used and are supplemented by an indicator of
expected claims for members with no claims history.
Specialty Variables
Building on MSK specific classifications incorporating body part and
procedures, details relating to the medical specialty of the lead
consultant are used as an indicator of members’ medical profile.
Demographic Based Variables
Basic demographics such as age and gender extended to include
details of membership, relationship status and a London treatment
indicator, to provide richer understanding of member base.
Clinical Based Variables
Clinical profile including chronic conditions and types of cancer
enhanced with indicators against specified pre-existing conditions, to
provide insight into potential claim areas for new members.

13. Bupa Private and Confidential
Project summary: Phases of development
13
Exploratory
analyses
Data
structuring
Methodology
Model
validation
1 month 5 months 14 weeks 2 months

14. REFERRAL
MANAGEMENT

15. Bupa Private and Confidential
Why influence the choice of provider?
15
GP specifies the clinical need and
specialty, we offer a choice of
consultants
• Just 7% of GPs saw their role as
‘making a facility or consultant
recommendation’1
• Only 24% of GPs felt they had access
to objective consultant information2
• 90% of GPs said they did not have
information to make an appropriate
referral2
1.: Office of Fair Trading (OFT) Consultant and GP survey
2.: GSK/Competition Commission Private Healthcare
Investigation Healthcare professional Jan 13

16. Bupa Private and Confidential
e.g. 1.2 million pieces of
data used in MSK
profiling, with different
levels of coverage and
..........medical history
3.7 million
invoices per
year
Specialty
specific clinical,
commercial and
statistical
analysis
Clinical and
commercial
validation and
sign off
Results inform
Specialist and
Facilities Finder
Specialist
management
and further
investigations
Lead by Medical
Directors, Senior
analytics and healthcare
managers with input
from consultants
treating Bupa members
Consultant Profiling
Profiling findings guide
future investigation:
- medical review of
consultant or specialty
- informs contracting
- commercial referral
Finder offers members
a choice of good quality
and value consultants
Rigorous checks and
sign off process to
ensure clinical and
commercial probity

17. Bupa Private and Confidential
Customer focus
Maintaining and driving best clinical quality
Identification of optimal cost effectiveness
Ensuring sufficient coverage of consultant specialists
Ensuring comparability
Adjustment for patient complexity
Speciality and sub-speciality
Minimum volume of members treated and location
Identification of
unexplained variation
Selection of clinical and cost indicators that identify variation
in practice
Management through contracts with consultants
Robustness and innovation
Specialist clinical support
Adherence to current best practice guidelines
Feedback from consultants, internal teams and customers
Profiling specialist care – Principles
Geographic coverage
Geographic coverage at specialty and sub specialty level
Consultants’ hospital affiliation
Adjustments made for expected travel time

18. Bupa Private and Confidential
Addressing unexplained variation
Cardiac Surgery Risk-Adjusted Mortality Rates (1st April 2009 – 31st March 2012). Society for Cardiothoracic Surgery in Great Britain & Ireland
Where a Specialists practice is markedly different from that of their peers without
clear explanation
 The dots are Surgeons
and the green dot is a
normal example
 Findings are risk
adjusted as some
surgeons will operate
on patients with
complex problems and
a higher risk of dying
 Specialists close to or
above the red line
may demonstrate
unexplained variation

19. Bupa Private and Confidential
How consultants are ranked
19
We identify and seek to understand variation in practice such as:
• High likelihood of surgery where this is not always the best option for the
patient (e.g. spine or knee surgery)
• Overuse of diagnostic tests (e.g. high use of CT scans)
• Longer than expected treatment (e.g. repeat unnecessary follow ups)
• Not meeting minimum procedure volumes (e.g. Less than 75 PCI’s per
year)
Where we identify unexplained variation in treatment, we may:
• Work with consultants to understand and reduce treatment variation
• Introduce medical reviews
• Not offer certain consultants to our members using the Referral
Management process
• Review and refine through feedback
Consultants are grouped into A, B or C
A: preferred consultants, B: too little data to tell, C: poor performers

20. Bupa Private and Confidential
Consultant and Facilities ‘Finder’
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• Contains information about over
23,000 consultants available through
Referral Management
• Ability to refine search criteria such
as speciality, distance, male/female
etc
• Consultants can update their own
profile with additional information
• A one stop shop for consultants,
hospitals, dental centres, Bupa
Centres and care homeshttp://finder.bupa.co.uk
Also available as an app on iPhone, Android and Blackberry