CISummit: Zach Henderson, Data-tastick: A Deep Dive on Data Driving Networks

DATA-TASTICK
A Deep Dive on Data Driving Networks

Zach Henderson
SVP, Healthcare Markets
Connected Insight Summit
© Health Market Science 2013, All Rights Reserved

It’s time to get excited about data…

We all think of

Data
in different ways


If you’re like me, as a bunch of 1s and 0s flowing through the pipes of
healthcare processing streams…

3


To many, it’s simply the content in spreadsheets…

4


For some, data is a little more simple than that…

5


Data often gets front page billing…

6


And some think of “Data” quite differently…

7


Data is sometimes frustrating…

8


And data became worse when it got “Big”

9


But when we finally understand Data, it is great!

10


BUT LET’S GET MORE SPECIFIC
We are in the Healthcare track at this conference after all

What types of data are available?
Type of Data

Prescription/Rx
Claims

Medical Claims

12

Benefits

Caveats

• Concentrated sources…
easier to collect
• Excellent for tracking retail
pharma products
• High coverage with weekly
updates available
• Known denominator

• Only usable for retail
tracking
• Variable correlation
between Rx activity and
medical activity

• Tailored to diagnosis and
procedure codes of interest
• Covers both retail and nonretail settings
• Best for identifying “splitting”
behavior of procedures
• Closest correlation to actual
referral networks

• Severely fragmented
• Difficult to source
• No standard
denominator/total
• Latency


Where do medical claims come from?
+50
State Databases
& Collaboratives

Claims Switches/
Clearinghouses

+4,000

+500

837

835

Office Practice
Management Software


Payers

Types of Claims Forms (UB-04)
• UB-04
• Institutional claims for services provided by hospitals, hospices,
and long-term care facilities (e.g. SNFs) are billed on Uniform
Bills (UB-04 or CMS-1450, formerly UB-92)
• All services are summarized by revenue codes
• For inpatient claims, UB-04 describes procedures primarily by
ICD-9 procedure codes
• For outpatient claims, UB-04 describes the services and
supplies provided by using CPT and HCPCS codes

• 1500
• Professional claims for services provided by physicians, labs,
ambulances, and DME vendors are billed on CMS 1500 forms
(HCFA 1500 or 1500 forms)
• CMS 1500 always describes the services and supplies provided
by using CPT and HCPCS codes
14


Medical Claim Form

Diagnosis Code:

• Glean useful
information:

ICD-9-CM code for appropriate
diagnosis or nature of illness

Drug Name & Strength, NDC: 12345-6789-01

› Physician ID,
diagnoses
and procedure
codes, facility
ID, etc

Office Visit Code:

174 9

CPT code for services provided
to an established patient

197 7

174 9
197 7

01 06 03 01 06 03 11

1

99211

01 06 03 01 06 03 11

01 06 03 01 06 03 11 06 1 0190782
01
03
06 03 11
01
03
06 03 11
01 06 03 01 06 03 11 06 1 01J9010

123-45-6789

1

1

99211

1

$$ $$

1
$$ $$
Procedure Code:

90782

1

1
$$ $$
1
$$ $$
CPT code for an injection
J9010
1
$$ $$
1
$$ $$

123-45-6789

xxx xx

xxx xx

John Brown, M.D.
111 Hospital Drive
Anytown, USA 12345

Required: Drug Code
123-45-6789

Appropriate HCPCS Drug Code
123-45-6789
for medication administered

xxx xx

xxx xx

John Brown, M.D.
111 Hospital Drive
Anytown, USA 12345

15


We almost forgot the most important part…

Patient Information:
The details on the unique patient

174 9
197 7

01 06 03 01 06 03 11

1

99211

1

01 06 03 01 06 03 11

1

90782

1

$$ $$
$$ $$

01 06 03 01 06 03 11

1

J9010

1

$$ $$

174 9
197 7
123-45-6789

123-45-6789

xxx xx

xxx xx

01 06 03 01 06 03 11

99211

1

90782

1

01 06 03 01 06 03 11

16

1

01 06 03 01 06 03 11

John Brown, M.D.
$$ $$
111 Hospital Drive
Anytown, USA 12345
$$ $$

1

J9010

1

$$ $$

1


But that is HIPAA data!!!

First
Name

Last
Name
Date
of
Birth

Magical Encryption/De-identification

Patient 123456

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So what?

PCP
Patient 123456

Specialist
Patient 123456

Cardiac Surgeon
Patient 123456

First off, healthcare companies can do a lot with data

10%

20%

30%

Understand where there is
opportunity to grow referrals

Identify areas of patient leakage

70%
20%
10%
Know where splitters
are “splitting”

Grow system/ACO through acquisitions,
partnerships and recruitment

Physician to Physician relationships are important
 Medical claims data can be used
to derive physician-physician
relationships based on shared
patients for a disease state of
interest.
 Analytic methodologies can
leverage longitudinal tracking of
patients across physician visits
by leveraging an anonymized
patient ID.
 A pair of physicians that share a
statistically significant number of
patients within a specified time
window are assumed to have a
professional relationship.
Is it a leap?

Example Network for a Service Line

Dr. Ashesh Jani
Dr. Monica Rizzo

Dr. Ruth O’Regan

Georgia network
Atlanta network
Zoom in to portion
of Atlanta network

22

Relationships for
Dr. O’Regan


A Provider Centric View of Competition in Cleveland
Dr. Michael Walker
Surgery, Orthopedic
9500 Euclid Ave
Cleveland, OH
Ortho National Rank - 9
Xian Jin
Internal Medicine
9500 Euclid Ave
Cleveland, OH

Strength of
Relationship

Jin

10

10
Ranjit Tamaskar
Internal Medicine
20000 Harvard Ave
Beachwood, OH

10

Tamaskar

10

Andrew Brobbey
Internal Medicine
25701 N Lakeland Blvd
Euclid, OH

8

Barbara Vizy
Family Practice
3690 Orange Pl
Beachwood, OH

Walker

7

8
Brobbey


7

Vizy

Shows a Referral Source that has relationship with 2 different systems

Dr. Ranjit Tamaskar
Internal Medicine
2000 Harvard Ave
Beachwood, OH

Michael Walker
Surgery, Orthopedic
9500 Euclid Ave
Cleveland, OH

Strength of
Relationship

Walker

10

10
Tamaskar

William Petersilge
Internal Medicine
20000 Harvard Ave
Beachwood, OH

6

6
Petersilge


Now that you can “see” how the data relates, it’s time
to put data into action

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QUESTIONS
Zach Henderson
SVP, Healthcare Markets

CISummit: Zach Henderson, Data-tastick: A Deep Dive on Data Driving Networks

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