1) Healthcare payers are facing increasing pressures to reduce costs while improving quality of care and consumer engagement. This is driving needs for modernized claims processing, population health management, and business intelligence solutions.
2) The document discusses various healthcare informatics and analytics solutions that can help payers address these challenges, including solutions for claims processing, care management, utilization management, disease management, wellness programs, and compliance and regulatory reporting.
3) It provides examples of how analytics can be used for cost containment, care coordination, and enabling accountable care through risk stratification, predictive modeling, and outcomes measurement.
Webinar Deck: The Changing Face of IT Outsourcing in the Healthcare Payer Mar...Everest Group
On June 5, Everest Group will host a one-hour webinar that will answer the following questions: What are the beneath-the-surface changes taking place in the payer IT industry? What are the trends and opportunities arising out of these changes? Why should CIOs start thinking of these transformational changes now? How should service providers assess their services portfolios and sales strategies from this transformational change perspective?
Healthcare ito in healthcare payer - annual report - preview deck - july 2013Everest Group
This report provides an overview of the ITO market for the healthcare payer industry. Analysis includes key trends in market size & growth, demand drivers, adoption & scope trends, emerging themes, key areas of investment, and implications for key stakeholders. The report also provides specific updates on the readiness of the various stakeholders from the perspective of payer reform mandates
Introduction to Population Health Analytics, Predictive Analytics, Big Data a...Frank Wang
UNH HCAD 6635 Healthcare Analytics Session 12, the last session of Health Information Analytics. Details of the topics of this session will be covered in HCAD 6637 "Advanced Analytics and Health Data Mining"
Webinar Deck: The Changing Face of IT Outsourcing in the Healthcare Payer Mar...Everest Group
On June 5, Everest Group will host a one-hour webinar that will answer the following questions: What are the beneath-the-surface changes taking place in the payer IT industry? What are the trends and opportunities arising out of these changes? Why should CIOs start thinking of these transformational changes now? How should service providers assess their services portfolios and sales strategies from this transformational change perspective?
Healthcare ito in healthcare payer - annual report - preview deck - july 2013Everest Group
This report provides an overview of the ITO market for the healthcare payer industry. Analysis includes key trends in market size & growth, demand drivers, adoption & scope trends, emerging themes, key areas of investment, and implications for key stakeholders. The report also provides specific updates on the readiness of the various stakeholders from the perspective of payer reform mandates
Introduction to Population Health Analytics, Predictive Analytics, Big Data a...Frank Wang
UNH HCAD 6635 Healthcare Analytics Session 12, the last session of Health Information Analytics. Details of the topics of this session will be covered in HCAD 6637 "Advanced Analytics and Health Data Mining"
In today’s healthcare market, financial challenges rank as the number one issue hospitals face. To maintain a margin to support their mission, hospital CEOs must always be on the lookout for opportunities to boost revenue through improved reimbursement. In this webinar, Thibodaux Regional Medical Center’s Greg Stock, president and chief executive officer, and Mikki Fazzio, director, HIM and clinical documentation improvement, as they share how Thibodaux Regional leveraged analytics to provide actionable feedback to continuously improve the process, and how you can too.
Managing ‘discharged not final billed’ (DNFB) cases is one important way hospitals can improve financial performance by increasing collection on bills with incomplete payment due to coding or documentation gaps. Historically, Thibodaux Regional’s DNFB caseload had reached 500 cases per month, with about a third of patients discharged without a completed bill due either to missing documentation or incomplete coding. Thibodaux Regional tackled this process problem by expanding the use of analytics to measure and track every aspect of their billing services. The results were impressive and sustainable. Three years after launching its initial DNFB redesign effort, Thibodaux Regional has realized $2.4M in additional annual reimbursement and a 61% relative reduction in DNFB dollars, as well as a 6.2 reduction in AR days, resulting in significantly improved cash flow.
View this webinar to learn how to:
- Increase reimbursement levels by optimizing workflow analytics
- Ease the documentation burden on overloaded physicians with time-efficient communication
- Provide critical analytics visibility to key stakeholders
A Reference Architecture for Digital Health: The Health Catalyst Data Operati...Health Catalyst
There are essentially four strategic options to address the enterprise data platform requirements of today’s healthcare systems: (1) build your own, (2) buy from EHR vendors, (3) look to a Silicon Valley high-tech startup, and (4) partner with Health Catalyst or a handful of similar companies.
In this webinar, Health Catalyst’s CTO, Dale Sanders, comments on all four approaches, hoping to help you to assess your organization’s strategy against the options and vendors in each category.
It’s been exactly three years since Health Catalyst embarked on a major investment in its next-generation technology, the Data Operating System (DOS™) and its applications. This webinar is an update on the progress, less about marketing the technology, but rather offering DOS as a reference architecture that can support analytics, AI, text processing, data-first application development, and interoperability, as an all-in-one agile cost-savings architecture.
In addition to the successes, Dale comments on the challenges that Health Catalyst has faced under a very ambitious DOS development plan. In its current state, DOS has made some significant improvements to overcome early mistakes, and is now a very solid enterprise data platform. In the interests of industry-wide learning, Sanders will talk transparently about those mistakes and how those learnings are being applied to the DOS platform, positioning it to evolve gracefully over the next 25 years.
View the webinar to learn how the DOS reference architecture:
- Helps manage the 2,000+ compulsory measures in US healthcare
- Enables applications as varied as a real-time patient safety surveillance system, and an activity-based costing system in one platform
- Can ingest data of any type or velocity from over 300 healthcare source systems and growing
- Bundles tools, applications, and analytics that would cost 3-6x more to build on your own
- Compares to EHR vendors as an option to serve as an enterprise data and analytics platform
- Is a performant, sustainable, and maintainable platform for deploying AI models in the natural flow of the healthcare data pipeline
- Provides curated data content and models while still allowing for the agility of a late binding design option
- Functions as a reference architecture that all healthcare organizations and vendors will ultimately have to build in their pursuit of digital health
Why Payers, Providers and Life Science/Pharma Must Join Forces to Achieve Tru...Health Catalyst
Is value-based care (VBC) the path to reducing the 18% of GDP that is spent on healthcare? It just may be, but all parties must play their part. Iya Khalil, chief commercial officer & co-founder at GNS Healthcare argues that in order for VBC to reach peak levels of performance and adoption, there must be a convergence of understanding between three key players: payers, providers and the life science industry.
These three parties have developed lifesaving innovations, tech-enabled new procedures, and advanced medical training that have all contributed over the last half century to push the US economy to spend an unsustainable amount on healthcare. Data and analytics are key to fixing this problem and are transforming the way that healthcare is delivered, however, VBC implementation remains complex. In this webinar Iya and Elia Stupka, SVP and general manager, life sciences business at Health Catalyst discuss how the healthcare industry reached this tipping point, why the move to VBC is so important, and how these parties can jointly work together to make healthcare sustainable.
View the webinar and learn:
- How you can make the move to VBC
- The importance of AI and data to drive VBC
VBC will happen and presents an unprecedented moment for payers, providers and life science groups to work together.
3 Perspectives to Better Apply Predictive & Prescriptive Models in HealthcareHealth Catalyst
In healthcare we tend to think of predictive or prescriptive model building and deployment as technical challenges. We do not put enough emphasis on the importance of change management. This disorientation leads to uneven adoption and results. In this webinar Jason Jones discusses and demonstrates three perspectives, accompanied by tools, to help you drive action and deliver better outcomes.
We develop predictive and prescriptive models in healthcare to improve Quadruple Aim outcomes—population health, patient experience, reduced cost, and positive provider work life. Successful adoption of predictive and prescriptive models heavily depends upon behavior change. This requires more than technical accuracy. While prediction algorithms abound, tools to facilitate change management remain scarce. During this webinar, we will discuss how to achieve model understanding using three perspectives: functional, contextual, and operational.
View the webinar to learn:
- Why a predictive or prescriptive model endeavor is more a change management challenge than a technical one
- How to apply three types of model understanding to a use case in your own organization
In this webinar, Jason Jones, PhD, Chief Data Scientist at Health Catalyst discusses and provides examples of our work using three perspectives of understanding to help clinical and operational leaders achieve value from predictive and prescriptive models. Investing time and effort to ensure model understanding is necessary for broad scale adoption.
Good surfers are the consummate analysts. They dynamically process streams of seemingly unrelated information bypassing lesser opportunities, then strategically selecting the perfect wave.
The ability to tease out genuine opportunities amidst a tumult of noise is a hallmark of great analysts. By viewing these slides you will learn:
- The human elements of a great analyst.
- How to re-frame the role of technology in analysis.
- Healthcare knowledge required to maximize the value of a healthcare analyst.
John Wadsworth's (Senior Vice President of Client Engagement, Health Catalyst) engaging presentation style leverages simple and fun analogies to galvanize key concepts for technical, clinical, and executive audiences alike. Join us as he brings principles from the world of surfing and applies them to healthcare analytics.
The Foundations of Success in Population Health ManagementHealth Catalyst
From hospital systems to large employers, organizations are increasingly taking on financial risk for the health of populations. Drivers of this trend include the update to the MSSP model, the recent CMS Primary Cares Initiative announcement, the increasing prevalence of the Medicare Advantage model, innovative partnerships in the self-insured employer space, and the proliferation of Medicaid ACOs. Yet while market pressures push organizations toward population risk, they don't necessarily help them succeed: most organizations are struggling to attain or sustain the dual imperatives of high-quality care and cost containment. A primary reason? Short-sighted and tactical approaches that don't provide the flexible data infrastructure and tools to adapt to emerging trends in population health—or to support short-term contractual requirements while building toward long-term success.
View this launch webinar to learn about Health Catalyst’s Population Health Foundations solution, a data and analytics-first starter set aimed at optimizing performance in value-based risk arrangements and providing the data ecosystem that will flex and adapt to complex needs of risk-bearing organizations. Solution services ensure that the strategic value of data is maximized to improve performance in risk contracts—and provide side-by-side subject matter expert partnership for establishing short- and long-term goals for population health management (PHM).
Built on Health Catalyst’s foundational technology and supported by the nationwide experience and perspective of its experts, the Population Health Foundations solution helps organizations leverage multiple data sources to understand their patient populations and create meaningful views of financial and clinical quality performance. As a starter set that organizations can build on based on their needs, the solution is designed to compensate for the known limitations of “black box” population health applications that fail to reveal the “why” of analytic insights and exacerbate the challenges of transforming quality, cost, and care. The Population Health Foundations solution delivers the essential analytic tools needed for success under value-based risk arrangements.
In these slides you can expect to:
- Review recent changes to the field of value-based care, and reactions and insights from the market
- Discover how the Population Health Foundations solution can act as a comprehensive, data-first analytics solution to support your population stratification and monitoring needs
- Understand how this solution functions as a foundational starter set for value-based care success, enabling clients to leverage all their data and other relevant population health tools
Healthcare Analytics: Right-Brain Advice in a Left-Brain WorldHealth Catalyst
U.S. healthcare is badly missing the soft, human side of healthcare analytics, especially as it impacts clinicians. How do we fix that? This webinar explores those ideas.
You won’t hear Dale talk about SQL, inner joins, outer joins, R, Python, logistic regression, random forest, or convolutional neural networks but instead, in this webinar he talks about the principles and philosophy of analytics.
For the most part, we’ve figured out the technology of analytics. That is all left-brain thinking—analytical, logical and methodical in nature—and it is literally getting easier every day with new data technology. But, in healthcare, we’re missing the right-brain thinking—creative and artistic in nature—that has almost nothing to do with technology but has everything to do with the human side of pursuing “data driven healthcare.”
Right-brain thinking is required for the oddities and shortcomings of healthcare data, and how to manage those shortcomings in the context of delivering data to the humans who we hope will consume it. The right-brain relates to the personality characteristics of the people who are leading your analytics strategy. It relates to the leadership culture of the organization and where that culture resides on a scale of transparency, internally and externally. The right-brain relates to behavioral economics, evolutionary psychology, human decision making theories, and the fundamental factors that motivate or demotivate human behavior. The right-brain relates to concepts like experimental design and PICO—patients, interventions, comparisons, and outcomes—that, if followed, can make your analytics more truthful and believable. It has to do with the way we negotiate and structure performance-based contracts that are loaded with quality metrics that either measure things that can’t be measured accurately or may measure the wrong thing, altogether.
You see, right-brained thinking in this left-brain world of analytics relates to a bunch of things, but mostly it relates to the Golden Rule of Data. Do unto others with data as you would have them do unto you.
Explains about Evolution of IT in Healthcare, how analytics can make a difference and evolution of IT in healtcare. For more information visit: http://www.transformhealth-it.org/
Payer Analytics In A Shifting Healthcare Landscape - June Presentation To Chi...Dan Wellisch
This is the June 2018 presentation to the Chicago Technology For Value-Based Healthcare https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Leveraging Predictive Models to Reduce ReadmissionsHealth Catalyst
Far too often analytics efforts have fallen short of making a tangible impact on outcomes because they haven’t been successfully implemented in real workflows. Predictive models remain at risk of becoming isolated in their use along the continuum of care where their integration may provide benefits larger than the sum of each silo.
To combat this, UnityPoint Health (UPH) focused on integrating analytical models within the same readmission reduction strategy and coaching the care team to facilitate their adoption. Using this approach, one of UPH hospital’s risk-adjusted readmission indexes improved 40 percent over three years, surpassing internal system targets in performance and becoming the top performer in the health system.
Learning Objectives:
- Describe applicable predictive models useful in reducing 30-day readmissions.
- Learn the elements of a successful readmissions reduction strategy in an integrated health system.
- Understand common obstacles faced in the adoption of analytical tools and how to overcome them.
View this webinar to gain knowledge of the analytics tools and methods UPH used, including innovative individualized risk heat-maps generated for each patient, strategies for analytics adoption, and lessons learned along the way.
Why Health Systems Must Use Data Science to Improve OutcomesHealth Catalyst
In today’s improvement-driven healthcare environment, organizations must ensure that improvement measures help them reach desired outcomes and focus on the opportunities with optimal ROI. With data science-based analysis, health systems leverage machine learning to determine if improvement measures align with specific outcomes and avoid the risk and cost of carrying out interventions that are unlikely to support their goals.
There are four essential reasons that insights from data science help health systems implement and sustain improvement:
Measures aligned with desired outcomes drive improvement.
Improvement teams focus on processes they can impact.
Outcome-specific interventions might impact other outcomes.
Identifies opportunities with optimal ROI.
Population Stratification Made Easy, Quick, and Transparent for AnyoneHealth Catalyst
One of the fundamental tasks when creating a population health initiative is to identify the right patients for the right interventions. The challenge with identifying patients is two-fold—there isn’t a one-size-fits all stratification method; and, current stratification tools prove to be inflexible, “black box” solutions that require time-consuming, technical expertise to customize the algorithms. Many commonly used stratification methods also fail to take advantage of the whole-patient picture, using the limited data sources that are available.
To address these challenges, Health Catalyst developed the Population Builder™️: Stratification Module; a fast, adaptable tool that allows for rapid and transparent stratification of patient groups based on predefined, yet easy to customize, populations and then provides the architecture to integrate the stratified populations into the population health workflow.
Based on the existing Population Builder tool, the Stratification Module consists of several population health building blocks that users can mix and match to create purpose-driven, transparent, and customizable populations to fit their needs. The building blocks save users the time and effort of creating the raw materials required for effective stratification by providing industry standard, evidence-based definitions for over 6,000 value sets, 21 predefined chronic condition registries, ED utilization (combined claims and clinical data), transition of care, and predictive risk models all in one tool. In addition, the power of AI is made accessible and easy with Health Catalyst-developed risk algorithms that are targeted to specific interventions.
View the Population Builder: Stratification Module webinar to learn more about its functionality, understand the customization process, observe a unique framework that integrates claims and clinical data, and make it easy to consume customized data sources, so that your algorithms include all of your available patient data.
In this webinar you can expect to:
- Learn how Population Builder: Stratification Module is used to combine data from multiple data sources—including claims and clinical data—to stratify based on a “whole patient picture.”
- Get a glimpse of the predefined stratification content that is packaged within the Population Builder: Stratification Module.
- Understand how the Population Builder: Stratification Module allows non-technical experts to quickly and transparently create sophisticated stratification algorithms.
- See how “published” patient lists, or registries, are created within Population Builder: Stratification Module and accessible by the DOS ecosystem.
Care Management Part 2 - A Critical Component of Effective Population HealthHealth Catalyst
Care management plays a central role in the world of value-based reimbursements, at-risk contracts, and population health management. Such programs require high-touch and resource-intensive care as teams work to deliver on the substantial promise of delivering patient care improvements while reducing costs.
Why Accurate Financial Data is Critical for Successful Value TransformationHealth Catalyst
Approximately 50 percent of CMS payments are now tied to a value component. The CMS Innovation Center has allocated nearly $5.4 billion to implement 37 value-based payment models, with 55 percent of those funds marked for development and implementation of additional value-based models. The shift towards value and consumerism is pushing providers to adopt a novel financial mindset and strategy. The key component? Accurate financial data.
In this webinar Steve Vance, senior vice president and executive advisor at Health Catalyst, explores why accurate financial data, coupled with specific tools and strategies, is critical for successful transformation.
View this webinar for key insights into thriving in a value-based environment:
- Why it’s time to embrace new payment methodologies.
- What role financial and clinical data play in value- and risk-based contracts.
- Various organizational and operational strategies for successful financial transformation.
- How Health Catalyst solutions support an innovative data-driven financial process.
Optimize Your Healthcare Data Quality Investment: Three Ways to Accelerate Ti...Health Catalyst
Healthcare organizations increasingly rely on data to inform strategic decisions. This growing dependence makes ensuring data across the organization is fit for purpose more critical than ever. Decision-making challenges associated with pandemic-driven urgency, variety of data, and lack of resources have further highlighted the critical importance of healthcare data quality and prompted more focus and investment. However, many data quality initiatives are too narrow in focus and reactive in nature or take longer than expected to demonstrate value. This leaves organizations unprepared for future events, like COVID-19, that require a rapid enterprise-wide analytic response.
What are some actionable ways you can help your organization guard against the data quality challenges uncovered this past year and better prepare to respond in the future? Join Taylor Larsen, Director of Data Quality for Health Catalyst, to learn more.
What You’ll Learn
- How data profiling and data quality assessments, in combination with your data catalog, can increase data quality transparency, expedite root cause analysis, and close data quality monitoring gaps.
- How to leverage AI to reduce data quality monitoring configuration and maintenance time and improve accuracy.
- How defining data quality based on its measurable utility (i.e., data represents information that supports better decisions) can provide a scalable way to ensure data are fit for purpose and avoid cost outstripping return.
In today’s healthcare market, financial challenges rank as the number one issue hospitals face. To maintain a margin to support their mission, hospital CEOs must always be on the lookout for opportunities to boost revenue through improved reimbursement. In this webinar, Thibodaux Regional Medical Center’s Greg Stock, president and chief executive officer, and Mikki Fazzio, director, HIM and clinical documentation improvement, as they share how Thibodaux Regional leveraged analytics to provide actionable feedback to continuously improve the process, and how you can too.
Managing ‘discharged not final billed’ (DNFB) cases is one important way hospitals can improve financial performance by increasing collection on bills with incomplete payment due to coding or documentation gaps. Historically, Thibodaux Regional’s DNFB caseload had reached 500 cases per month, with about a third of patients discharged without a completed bill due either to missing documentation or incomplete coding. Thibodaux Regional tackled this process problem by expanding the use of analytics to measure and track every aspect of their billing services. The results were impressive and sustainable. Three years after launching its initial DNFB redesign effort, Thibodaux Regional has realized $2.4M in additional annual reimbursement and a 61% relative reduction in DNFB dollars, as well as a 6.2 reduction in AR days, resulting in significantly improved cash flow.
View this webinar to learn how to:
- Increase reimbursement levels by optimizing workflow analytics
- Ease the documentation burden on overloaded physicians with time-efficient communication
- Provide critical analytics visibility to key stakeholders
A Reference Architecture for Digital Health: The Health Catalyst Data Operati...Health Catalyst
There are essentially four strategic options to address the enterprise data platform requirements of today’s healthcare systems: (1) build your own, (2) buy from EHR vendors, (3) look to a Silicon Valley high-tech startup, and (4) partner with Health Catalyst or a handful of similar companies.
In this webinar, Health Catalyst’s CTO, Dale Sanders, comments on all four approaches, hoping to help you to assess your organization’s strategy against the options and vendors in each category.
It’s been exactly three years since Health Catalyst embarked on a major investment in its next-generation technology, the Data Operating System (DOS™) and its applications. This webinar is an update on the progress, less about marketing the technology, but rather offering DOS as a reference architecture that can support analytics, AI, text processing, data-first application development, and interoperability, as an all-in-one agile cost-savings architecture.
In addition to the successes, Dale comments on the challenges that Health Catalyst has faced under a very ambitious DOS development plan. In its current state, DOS has made some significant improvements to overcome early mistakes, and is now a very solid enterprise data platform. In the interests of industry-wide learning, Sanders will talk transparently about those mistakes and how those learnings are being applied to the DOS platform, positioning it to evolve gracefully over the next 25 years.
View the webinar to learn how the DOS reference architecture:
- Helps manage the 2,000+ compulsory measures in US healthcare
- Enables applications as varied as a real-time patient safety surveillance system, and an activity-based costing system in one platform
- Can ingest data of any type or velocity from over 300 healthcare source systems and growing
- Bundles tools, applications, and analytics that would cost 3-6x more to build on your own
- Compares to EHR vendors as an option to serve as an enterprise data and analytics platform
- Is a performant, sustainable, and maintainable platform for deploying AI models in the natural flow of the healthcare data pipeline
- Provides curated data content and models while still allowing for the agility of a late binding design option
- Functions as a reference architecture that all healthcare organizations and vendors will ultimately have to build in their pursuit of digital health
Why Payers, Providers and Life Science/Pharma Must Join Forces to Achieve Tru...Health Catalyst
Is value-based care (VBC) the path to reducing the 18% of GDP that is spent on healthcare? It just may be, but all parties must play their part. Iya Khalil, chief commercial officer & co-founder at GNS Healthcare argues that in order for VBC to reach peak levels of performance and adoption, there must be a convergence of understanding between three key players: payers, providers and the life science industry.
These three parties have developed lifesaving innovations, tech-enabled new procedures, and advanced medical training that have all contributed over the last half century to push the US economy to spend an unsustainable amount on healthcare. Data and analytics are key to fixing this problem and are transforming the way that healthcare is delivered, however, VBC implementation remains complex. In this webinar Iya and Elia Stupka, SVP and general manager, life sciences business at Health Catalyst discuss how the healthcare industry reached this tipping point, why the move to VBC is so important, and how these parties can jointly work together to make healthcare sustainable.
View the webinar and learn:
- How you can make the move to VBC
- The importance of AI and data to drive VBC
VBC will happen and presents an unprecedented moment for payers, providers and life science groups to work together.
3 Perspectives to Better Apply Predictive & Prescriptive Models in HealthcareHealth Catalyst
In healthcare we tend to think of predictive or prescriptive model building and deployment as technical challenges. We do not put enough emphasis on the importance of change management. This disorientation leads to uneven adoption and results. In this webinar Jason Jones discusses and demonstrates three perspectives, accompanied by tools, to help you drive action and deliver better outcomes.
We develop predictive and prescriptive models in healthcare to improve Quadruple Aim outcomes—population health, patient experience, reduced cost, and positive provider work life. Successful adoption of predictive and prescriptive models heavily depends upon behavior change. This requires more than technical accuracy. While prediction algorithms abound, tools to facilitate change management remain scarce. During this webinar, we will discuss how to achieve model understanding using three perspectives: functional, contextual, and operational.
View the webinar to learn:
- Why a predictive or prescriptive model endeavor is more a change management challenge than a technical one
- How to apply three types of model understanding to a use case in your own organization
In this webinar, Jason Jones, PhD, Chief Data Scientist at Health Catalyst discusses and provides examples of our work using three perspectives of understanding to help clinical and operational leaders achieve value from predictive and prescriptive models. Investing time and effort to ensure model understanding is necessary for broad scale adoption.
Good surfers are the consummate analysts. They dynamically process streams of seemingly unrelated information bypassing lesser opportunities, then strategically selecting the perfect wave.
The ability to tease out genuine opportunities amidst a tumult of noise is a hallmark of great analysts. By viewing these slides you will learn:
- The human elements of a great analyst.
- How to re-frame the role of technology in analysis.
- Healthcare knowledge required to maximize the value of a healthcare analyst.
John Wadsworth's (Senior Vice President of Client Engagement, Health Catalyst) engaging presentation style leverages simple and fun analogies to galvanize key concepts for technical, clinical, and executive audiences alike. Join us as he brings principles from the world of surfing and applies them to healthcare analytics.
The Foundations of Success in Population Health ManagementHealth Catalyst
From hospital systems to large employers, organizations are increasingly taking on financial risk for the health of populations. Drivers of this trend include the update to the MSSP model, the recent CMS Primary Cares Initiative announcement, the increasing prevalence of the Medicare Advantage model, innovative partnerships in the self-insured employer space, and the proliferation of Medicaid ACOs. Yet while market pressures push organizations toward population risk, they don't necessarily help them succeed: most organizations are struggling to attain or sustain the dual imperatives of high-quality care and cost containment. A primary reason? Short-sighted and tactical approaches that don't provide the flexible data infrastructure and tools to adapt to emerging trends in population health—or to support short-term contractual requirements while building toward long-term success.
View this launch webinar to learn about Health Catalyst’s Population Health Foundations solution, a data and analytics-first starter set aimed at optimizing performance in value-based risk arrangements and providing the data ecosystem that will flex and adapt to complex needs of risk-bearing organizations. Solution services ensure that the strategic value of data is maximized to improve performance in risk contracts—and provide side-by-side subject matter expert partnership for establishing short- and long-term goals for population health management (PHM).
Built on Health Catalyst’s foundational technology and supported by the nationwide experience and perspective of its experts, the Population Health Foundations solution helps organizations leverage multiple data sources to understand their patient populations and create meaningful views of financial and clinical quality performance. As a starter set that organizations can build on based on their needs, the solution is designed to compensate for the known limitations of “black box” population health applications that fail to reveal the “why” of analytic insights and exacerbate the challenges of transforming quality, cost, and care. The Population Health Foundations solution delivers the essential analytic tools needed for success under value-based risk arrangements.
In these slides you can expect to:
- Review recent changes to the field of value-based care, and reactions and insights from the market
- Discover how the Population Health Foundations solution can act as a comprehensive, data-first analytics solution to support your population stratification and monitoring needs
- Understand how this solution functions as a foundational starter set for value-based care success, enabling clients to leverage all their data and other relevant population health tools
Healthcare Analytics: Right-Brain Advice in a Left-Brain WorldHealth Catalyst
U.S. healthcare is badly missing the soft, human side of healthcare analytics, especially as it impacts clinicians. How do we fix that? This webinar explores those ideas.
You won’t hear Dale talk about SQL, inner joins, outer joins, R, Python, logistic regression, random forest, or convolutional neural networks but instead, in this webinar he talks about the principles and philosophy of analytics.
For the most part, we’ve figured out the technology of analytics. That is all left-brain thinking—analytical, logical and methodical in nature—and it is literally getting easier every day with new data technology. But, in healthcare, we’re missing the right-brain thinking—creative and artistic in nature—that has almost nothing to do with technology but has everything to do with the human side of pursuing “data driven healthcare.”
Right-brain thinking is required for the oddities and shortcomings of healthcare data, and how to manage those shortcomings in the context of delivering data to the humans who we hope will consume it. The right-brain relates to the personality characteristics of the people who are leading your analytics strategy. It relates to the leadership culture of the organization and where that culture resides on a scale of transparency, internally and externally. The right-brain relates to behavioral economics, evolutionary psychology, human decision making theories, and the fundamental factors that motivate or demotivate human behavior. The right-brain relates to concepts like experimental design and PICO—patients, interventions, comparisons, and outcomes—that, if followed, can make your analytics more truthful and believable. It has to do with the way we negotiate and structure performance-based contracts that are loaded with quality metrics that either measure things that can’t be measured accurately or may measure the wrong thing, altogether.
You see, right-brained thinking in this left-brain world of analytics relates to a bunch of things, but mostly it relates to the Golden Rule of Data. Do unto others with data as you would have them do unto you.
Explains about Evolution of IT in Healthcare, how analytics can make a difference and evolution of IT in healtcare. For more information visit: http://www.transformhealth-it.org/
Payer Analytics In A Shifting Healthcare Landscape - June Presentation To Chi...Dan Wellisch
This is the June 2018 presentation to the Chicago Technology For Value-Based Healthcare https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
Leveraging Predictive Models to Reduce ReadmissionsHealth Catalyst
Far too often analytics efforts have fallen short of making a tangible impact on outcomes because they haven’t been successfully implemented in real workflows. Predictive models remain at risk of becoming isolated in their use along the continuum of care where their integration may provide benefits larger than the sum of each silo.
To combat this, UnityPoint Health (UPH) focused on integrating analytical models within the same readmission reduction strategy and coaching the care team to facilitate their adoption. Using this approach, one of UPH hospital’s risk-adjusted readmission indexes improved 40 percent over three years, surpassing internal system targets in performance and becoming the top performer in the health system.
Learning Objectives:
- Describe applicable predictive models useful in reducing 30-day readmissions.
- Learn the elements of a successful readmissions reduction strategy in an integrated health system.
- Understand common obstacles faced in the adoption of analytical tools and how to overcome them.
View this webinar to gain knowledge of the analytics tools and methods UPH used, including innovative individualized risk heat-maps generated for each patient, strategies for analytics adoption, and lessons learned along the way.
Why Health Systems Must Use Data Science to Improve OutcomesHealth Catalyst
In today’s improvement-driven healthcare environment, organizations must ensure that improvement measures help them reach desired outcomes and focus on the opportunities with optimal ROI. With data science-based analysis, health systems leverage machine learning to determine if improvement measures align with specific outcomes and avoid the risk and cost of carrying out interventions that are unlikely to support their goals.
There are four essential reasons that insights from data science help health systems implement and sustain improvement:
Measures aligned with desired outcomes drive improvement.
Improvement teams focus on processes they can impact.
Outcome-specific interventions might impact other outcomes.
Identifies opportunities with optimal ROI.
Population Stratification Made Easy, Quick, and Transparent for AnyoneHealth Catalyst
One of the fundamental tasks when creating a population health initiative is to identify the right patients for the right interventions. The challenge with identifying patients is two-fold—there isn’t a one-size-fits all stratification method; and, current stratification tools prove to be inflexible, “black box” solutions that require time-consuming, technical expertise to customize the algorithms. Many commonly used stratification methods also fail to take advantage of the whole-patient picture, using the limited data sources that are available.
To address these challenges, Health Catalyst developed the Population Builder™️: Stratification Module; a fast, adaptable tool that allows for rapid and transparent stratification of patient groups based on predefined, yet easy to customize, populations and then provides the architecture to integrate the stratified populations into the population health workflow.
Based on the existing Population Builder tool, the Stratification Module consists of several population health building blocks that users can mix and match to create purpose-driven, transparent, and customizable populations to fit their needs. The building blocks save users the time and effort of creating the raw materials required for effective stratification by providing industry standard, evidence-based definitions for over 6,000 value sets, 21 predefined chronic condition registries, ED utilization (combined claims and clinical data), transition of care, and predictive risk models all in one tool. In addition, the power of AI is made accessible and easy with Health Catalyst-developed risk algorithms that are targeted to specific interventions.
View the Population Builder: Stratification Module webinar to learn more about its functionality, understand the customization process, observe a unique framework that integrates claims and clinical data, and make it easy to consume customized data sources, so that your algorithms include all of your available patient data.
In this webinar you can expect to:
- Learn how Population Builder: Stratification Module is used to combine data from multiple data sources—including claims and clinical data—to stratify based on a “whole patient picture.”
- Get a glimpse of the predefined stratification content that is packaged within the Population Builder: Stratification Module.
- Understand how the Population Builder: Stratification Module allows non-technical experts to quickly and transparently create sophisticated stratification algorithms.
- See how “published” patient lists, or registries, are created within Population Builder: Stratification Module and accessible by the DOS ecosystem.
Care Management Part 2 - A Critical Component of Effective Population HealthHealth Catalyst
Care management plays a central role in the world of value-based reimbursements, at-risk contracts, and population health management. Such programs require high-touch and resource-intensive care as teams work to deliver on the substantial promise of delivering patient care improvements while reducing costs.
Why Accurate Financial Data is Critical for Successful Value TransformationHealth Catalyst
Approximately 50 percent of CMS payments are now tied to a value component. The CMS Innovation Center has allocated nearly $5.4 billion to implement 37 value-based payment models, with 55 percent of those funds marked for development and implementation of additional value-based models. The shift towards value and consumerism is pushing providers to adopt a novel financial mindset and strategy. The key component? Accurate financial data.
In this webinar Steve Vance, senior vice president and executive advisor at Health Catalyst, explores why accurate financial data, coupled with specific tools and strategies, is critical for successful transformation.
View this webinar for key insights into thriving in a value-based environment:
- Why it’s time to embrace new payment methodologies.
- What role financial and clinical data play in value- and risk-based contracts.
- Various organizational and operational strategies for successful financial transformation.
- How Health Catalyst solutions support an innovative data-driven financial process.
Optimize Your Healthcare Data Quality Investment: Three Ways to Accelerate Ti...Health Catalyst
Healthcare organizations increasingly rely on data to inform strategic decisions. This growing dependence makes ensuring data across the organization is fit for purpose more critical than ever. Decision-making challenges associated with pandemic-driven urgency, variety of data, and lack of resources have further highlighted the critical importance of healthcare data quality and prompted more focus and investment. However, many data quality initiatives are too narrow in focus and reactive in nature or take longer than expected to demonstrate value. This leaves organizations unprepared for future events, like COVID-19, that require a rapid enterprise-wide analytic response.
What are some actionable ways you can help your organization guard against the data quality challenges uncovered this past year and better prepare to respond in the future? Join Taylor Larsen, Director of Data Quality for Health Catalyst, to learn more.
What You’ll Learn
- How data profiling and data quality assessments, in combination with your data catalog, can increase data quality transparency, expedite root cause analysis, and close data quality monitoring gaps.
- How to leverage AI to reduce data quality monitoring configuration and maintenance time and improve accuracy.
- How defining data quality based on its measurable utility (i.e., data represents information that supports better decisions) can provide a scalable way to ensure data are fit for purpose and avoid cost outstripping return.
Three Keys to a Successful Margin: Charges, Costs, and LaborHealth Catalyst
How can cost management and complete charge capture protect and enhance the margin?
In this webinar, we will look at 2024 margin pressures likely to impact your organization’s financial resiliency. This presentation will also share how organizations can move from Fee-for-Service to Value; bringing Cost to the forefront.
Population Health Management: Enabling Accountable Care in Collaborative Prov...Salus One Ed
This document provides the reader information about population health management (PMH), how it relates to incentive payments for healthcare providers and their health insurance partners (commercial and government). See details about required transformation of care delivery methods, typical accountable care payment models, how to achieve incentives, partnerships between state government (public health) and community shared services needs and necessary technology and data to achieve it.
Surviving Value-Based Purchasing in Healthcare: Connecting Your Clinical and ...Health Catalyst
Reducing healthcare costs is a major driving force in bundled payments, home-centered medical care, and accountable care organizations. But each new delivery model is built on the premise of reducing revenue per patient. So how can a health system win? Find out what you can do financially survive in today’s environment.
2023 — Focus on the Margin (Vitalware by Health Catalyst)Health Catalyst
In this webinar, we will look at pressures exerted in 2023 on the margin and explore how cost management and complete charge capture can protect and enhance the margin. We will provide details on patient activity costing versus the cost-to-charge ratio (CCR), looking at common themes for lost charges and providing an example of where patient activity cost management was able to provide insight into cost containment and practice patterns of a system provider.
in order to meet cost reduction targets, CMOs
* Share patient data across ecosystems
* Embed shared organizational intelligence
* Establish guidance for quality & cost within physician workflows
* Prepare physician leaders to create a culture of continual improvement
Workplace productivity is an estimate of how efficiently organizations utilize their resources to accomplish business objectives. Improving productivity is important because increasing it can increase revenue using the same or fewer resources.
Streamlining Your Medical Practice for Profitability and SuccessConventus
Conventus webinar video providing key success strategies and tactics for improving productivity, profitability, and patient care. The one-hour video features host Susan Lieberman of Conventus and Stevie Davidson of Health Informatics Consulting.
Population Health Management, Predictive Analytics, Big Data and Text AnalyticsFrank Wang
HCAD 6635 Health Information Analytics session 12
Population Health Management Analytics
Predictive Analytics
Big Data and its potential applications in Healthcare
Text Analytics
Public Health Analytics
Information Management In Pharmaceutical IndustryFrank Wang
Pharmaceutical Industry Information Management Opportunities and Challenges in Research, Development, Clinical, Sales, Marketing, Managed Markets, Manufacturing, Supply Chain and Distribution
2. 2
THE FACES OF HEALTHCARE
Anatomy of a medical transaction
Emotional… Complex… Fragmented… Paper-based
Source: Life Magazine
3. 3
Healthcare Client Needs are Changing to Address Drivers
Cost Reduction
Consumer
Engagement
Interoperability
Business
Intelligence
Management
Data
Management
• Pressure to reduce operating costs due to restrictions on Medial Loss Ratios
• Health Exchange-enabled Individual market requires a low cost structure
• Health plans will need to re-allocate capital to new product and growth initiatives
• Claims processing system modernization becomes increasingly important
• Consumerism and Individual Markets are shifting the business model
• Increased number of Medicare and Medicaid membership
• Multi-channel customer engagement is needed
• Cloud CRM
• Accountable Care Organizations will require new partnerships with providers
• Greater alignment of incentives among pharma, health plans and health providers
requires collaboration
• Global Network Infrastructure expansion to support growing business needs and
industry interconnectivity
• Health plans and their partners will need to manage significantly more health data
• Dashboards and other insight tools can reduce operational costs
• Social network analytics is emerging
• Real Time Data/Knowledge in support of Strategic Decision Making
• ICD-10 is impacting critical applications and infrastructure
• Individuals moving between plans increase demand for data security and integrity
• Connectivity with individual end-point devices (tablets, smart phones) require increased
data security
• New healthcare delivery models in support of evidence-based medicine and
personalize medicine yield data types unfamiliar to most payers
4. 4
BUSINESS VALUE ANALYSIS OF INFORMATION MANAGEMENT IN HEALTHCARE
ULTIMATE BUSINESS GOAL Speed Innovation to Practice Improve Quality of CareImprove Operational Efficiencies
COST CONTAINMENT
---------------------------
Cut Operating Expense
QUALITY OF CARE
----------------------------
Minimizing Medical Errors
COMPLIANCE
----------------------------
100% compliance
(HIPAA, HITECH etc.)
PATIENT THROUGHPUT
---------------
Increase: 10% per year
ULTIMATE BUSINESS GOAL
EXECUTIVE KPIs
(Direction)
COST x Claim
-------------
Decrease
ERROR RATE
---------------
Errors: 0% in
5 years
In-patients per bed
per year
----------------------------
Increase
COST x Bill
-------------
Decrease
CORE KPIs
(Direction)
LENGTH OF STAY
----------------------------
Decrease
BUSINESS
INITIATIVES
(Strategy/Priority
Language)
Improve efficiency of
Clinical decision making and
Emergency services
Improve quality of healthcare
services while reducing costs
Manage information for
efficiency and compliance
Improve diagnostic process
efficiency and patient data
integration
OPERATING
KPIs
--------------------
PROCESS/
FUNCTION
Reduce time frame of medical
service delivery and emergency
Patient response.
--------------
Improve clinical decision support
and information sharing among
healthcare stakeholders
Reduce diagnostic imaging/
data complexity
------------------
Improve access to diagnostic
information across clinical
department
SAMPLE
SOLUTION
Enable new care management
and risk modeling applications
------------------
Improve access to patient
information from disparate
sources
Design, develop and deliver a
web-based interface for
information sharing
Implement cost effective storage
optimization and scalable data
protection
Construct a single data ware-
house to enable leveraging of
information as a corporate asset
Implement cost effective
PACS/RISS integration
Mitigate potential data loss
without a cost increase
--------------
Optimize storage capacity while
protecting ‘business critical’ data
ROA(Asset
Utilization)
---------------
Increase
5. 5
The journey to accountable care requires a Healthcare IT
Transformation across the entire community of care
Integrated
Health
System
Optimized
Healthcare
IT System
Physician
Office
Hospitals
and
Clinics
Lab
Facilities
Long
Term
Care
Facility
Government/
Commercial
Payors
Imaging
Center
Home
Health
Outpatient
Surgery
Center
Pharmacy/
PBMs
Healthcare Transformation IT
Requirements
• Upgrade, automate and connect
healthcare IT systems across acute,
ambulatory, clinic and home settings
• Deliver an integrated clinical and
financial view of a patient on demand
• Deploy “collaborative” systems to
enable “team” based community care
• Establish Business intelligence
platforms for reporting, outcomes
measurement and disease
management
• Accelerate standardization and cost
take out activities ahead of new
system installs
6. 6
The 8 Building Blocks of Successful Accountable HealthcarePayforReportingPayforOutcomes
EHR/PMS/
E-Prescribing 2. Automating and Integrating Fragmented Stakeholders
Information
Exchange
(HIE)
3. Sharing Clinical, Operations and Financial Information
Aggregation &
Analytics 4. Aggregating Siloed Data and Gaining Insight
Decision
Support 5. Transforming collected data into clinical knowledge
Healthcare
Portals and
Medical Homes
6. Making clinical information accessible and “team-based” care
possible
Outcomes
Measurement &
Reporting
7. Establishing Core Measures and Reporting Outcomes
Risk
Sharing 8. Enabling Population Based Management and Risk Sharing Models
Converged
Medical
Infrastructure
1. Establishing Standardized and Optimized IT Platforms
7. 7
Healthcare Payer Informatics and Analytics Solution Landscape
Unique
Individual
- Member,
Provider,
Agent, etc.
Claims
Fees
Lab
Member
Premium
Eligibility
EBM
Groupers
CM/WM
Program
EMR
Risk
Care Management / Medical Management
Program
Effectiveness
Outcomes
Analytics
Population
Analysis
CM/DM/WM
Analysis
Case
Management
Outcomes
Member
Engagement
HEDIS
Pay 4
Performance
Bundled Pmt
Analytics
Shared
Savings
Cost Trends
Market
Analytics
Employer
Engagement
Provider
Engagement
ACO
HIE
HIX
Sales Forces
Analytics
NCQA
many more…
Account
Management
CMS
State
Reporting
8. 8
Cost and Revenue Analytics
Understand your financial metrics and trend analysis
Multi-faceted
• Fraud, underwriting, MLR, clinical
and coding guideline
Timely
• Reporting at the time of processing
claims or claim submission
What-if
Scenario
• Leverage “what-if” analysis to
identify effective responses to cost
drivers
9. 9
Supporting the BI needs of Healthcare Payers as they engage members in ongoing care
management along the health continuum
Care Management Model
Evaluate
Measure outcomes and
adjust performance
Intervene
Targeted, evidence
based methods to
impact the
member’s condition
and health
Enroll
Incentivize and engage
members to participate
Identify & Target
Right member; right program
1
2
3
4
10. 10
Care Management Portal
Member-
centric
•Member-centric view tracking and reporting members’ health
conditions, goals, recommended interventions and outcomes so that
care managers can assess overall program effectiveness
Integration
•Integrates with claims data to identify members with existing or
developing chronic diseases, calculates treatment plan cost savings,
and track results
Easy to use
•An easy to use care management portal
11. 11
Care management to reduce hospital readmission rates
Care Management
– Fraud, underwriting, cost trending, general
admin costs; clinical and coding guidelines
– Identify and analyze your cost drivers
– Reporting at the time of processing claims or
claim submission
– What do you do next?
– Leverage ‘what-if’ analysis to identify effective
responses to cost drivers
– Analyze fraud patterns pre-payment and
streamline response; early intervention
Comprehensive
•From prevention to long-term
chronic disease maintenance
Predictable
•Predictive modeling at patient
and population levels to
reduce hospital readmission
rates
Multiple data
sources
•Leverage many different data
sources
12. 12
Use Case: Stratification for Care Intervention
Mr. HP1 – 20 years, blood pressure 120 / 80
Mr. HP2 – 30 years, blood pressure 140 / 90, 15 lbs
overweight, borderline high fasting blood sugar (115 mg/dl)
Mr. HP3 – 40 years, blood pressure 155 / 110, 50 lbs
overweight, repeated high fasting blood sugar (140 mg/dl )
Is at risk of developing a chronic condition
that can be minimized through better
understanding and improved self care. He
has a medium risk score. He is placed into
a Disease Management program to optimize
blood pressure control, achieve moderate
weight reduction, and incorporate dietary
modification.
Has a chronic condition that puts him at
high risk for getting progressively worse. In
this case, preventing or slowing progression
is the goal. He is placed in a Case
Management (CM) program.
The challenge is to correctly assess who is at risk, quantify the risk, then
match the individual with the best care intervention.Is healthy and thus has a very low risk
score. Based on this, he is directed to
the Wellness program.
13. 13
Use Case – Case Management
– Identifying High Risk High Cost (HRHC) Members
• Identify members who are at high risk for experiencing decreased
health or likely to incur high dollar cost for treatments.
• Separate long-term HRHC members (advanced chronic disease
suffers) from one time high cost members (trauma)
• Stratify long-term HRHC members in order to assign appropriate
intervention by Case Management (CM)
– Benefit
• Lower immediate costs
• Much lower long term cost (bend the trend)
• Target intervention by Case Mangement to improve member health,
keep the member healthier for longer period of time, delay the
worsening of health.
14. Insurance Performance – Case Management
Member
ID
First
name
Last
Name
Age Total Cost
Expected Amount
Year 2
1 De-ID De-ID 60 $10,565 $109,051.00
2 De-ID De-ID 61 $27,013 $78,934.00
3 De-ID De-ID 50 $28,805 $51,971.00
4 De-ID De-ID 59 $8,372 $66,154.00
5 De-ID De-ID 86 $17,674 $65,604.00
6 De-ID De-ID 61 $420,318 $14,575.00
7 De-ID De-ID 55 $29,925 $48,609.00
8 De-ID De-ID 54 $4,828 $55,133.00
9 De-ID De-ID 87 $5,161 $55,062.00
10 De-ID De-ID 5 $620,887 $5,570.00
One time event
(Blue)
• Little impact for future
• Goal: encourage healthy behavior
Continued
progression (Yellow)
• Slow progression, moderate affect long term costs
• Goal: Extend time the member feels healthy
Sudden change for
the worse (Red)
• Rapid progression into disease, large affect on
long-term costs
• Goal: Stop or moderate descent into disease
15. 15
Utilization Management (UM)
Appropriateness
•Reviews prior authorization, eligibility, benefits
limits and services limits
Necessity
•Provides concurrent and retrospective reviews
based on evidence-based guidelines, clinical
criteria (InterQual, Milliman, Solucient)
Efficiency
•Proactively manages therapeutic duplication,
level of care and length of services
16. 16
Disease Management and Wellness Management
Segment
and Predict
•Segments and predicts specific illness
such as heart conditions, diabetes
and depression
Wellness
Plan
•Member centric wellness management
including health risk assessment,
patient education
Cost
Containment
•Develop short- and long-term cost
control machnism
17. 17
Cost Containment Findings
Provider
#
Count Provider Name Specialty Total $
1 4836 Bing, Mark Family Practice $160,833
2 4342 Yahoo, Charles Psychiatry $143,490
3 2732 East End Urgent Care URGENT Family Practice $90,479
4 2602 Place, First MD General Practice $63,892
5 1724 Swat, Edward MD Anesthesiology $56,696
6 4312 Smith, Gregory E DPM Podiatry $54,597
7 3836 Man, Super G DPM Podiatry $49,796
8 1615 Riley, James R MD Plastic Surgery $37,970
9 3243 Avian, Bird DPM Podiatry $37,327
10 2513 Copper, Metal H DPM Podiatry $32,668
Reduce costs by identifying and eliminating un-necessary procedures
Necessity
• Is the procedure necessary
Savings
• How large is the potential saving and what
is the estimated cost/benefit ratio?
Nail
Debridement
•Nail debridement clinical guidelines. Only 2 of 5 are directly tied to a disease
•Relief of pain
•Treatment of infection (bacterial, fungal and viral)
•Temporary removal of an anatomic deformity …
•Exposure of subungal condition …
•Prophylactic measure to prevent further problems …
18. Fraud and Abuse Detection
Additional investigation needed
Provider
#
Count Provider Name Specialty Total $
1 4836 Bing, Mark Family Practice $160,833
2 4342 Yahoo, Charles Psychiatry $143,490
3 2732 East End Urgent Care
URGENT
Family Practice $90,479
4 2602 Place, First MD General Practice $63,892
5 1724 Swat, Edward MD Anesthesiology $56,696
6 4312 Smith, Gregory E
DPM
Podiatry $54,597
7 3836 Man, Super G DPM Podiatry $49,796
8 1615 Riley, James R MD Plastic Surgery $37,970
9 3243 Avian, Bird DPM Podiatry $37,327
10 2513 Copper, Metal H DPM Podiatry $32,668
Provider1
• Charges significantly higher than his
peers
Provider 2
• Specialized in psychiatry, and is not
generally associated with nail
debridement
Provider 5
• Practiced in a specialty that is not
generally associated with the nail
debridement procedure
19. 19
Fraud and Abuse (F&A) Detection by Profiling Providers
Ranking Top 5 Codes by Quantity for Provider: GR0000000 – ABC Medical Group, Inc
6 Months of Service xx/xx-yy/yy, Paid in Months xx/xx-yy/yy
GR0000000
Qty Rank and % Compared to
OB/GYN Groups
6 Month Peer
Averages
Code Code Desc
Total Dollars
Paid
Total
Qty
Adj Rank
% of
Total
Qty
Total
#
Provs
Peer Avg
Dollars
Paid
Peer
Avg
Qty
81025-TC Urine pregnancy test $12,560.60 2,710 #1 or 19% 65 $1,022.93 220
Z9752
Family planning counseling (15
minutes) $33,086.45 1,735 #1 or 21% 55 $2,778.90 149
Z6410
Perinatal education, individual,
each 15 minutes $9,511.71 1,131 #9 or 3% 91 $3,657.38 435
Z6204
Follow-up antepartum nutrition
assessment, treatment and/or
intervention; individual, each 15
minutes $7,569.00 900 #5 or 4% 96 $2,074.14 247
Z1034 Antepartum follow-up visit $48,625.92 804 #16 or 2% 195 $11,996.08 203
Outlier detection based on Provider profiles. Highlighted cells suggest
further investigation.
20. 20
Health Information Exchange
Singular
• Houses data from many clinical data sources in
a secure central structure
Enabling
• Enables key functions that reduces costs
(reduced repeated testing, reduced risk of
adverse events) and improves coordination of
care
Payer
• Some HIE use cases have focus on sending
ADTs (admissions, discharges, transfers) and
discharge summaries to the health plans in lieu
of manual processing
21. 21
HIE DISTRIBUTION LAYER BUILT FOR GROWTH
Collaborate regionally and cross- border with
other states
Offer clear guidance and flexible access to
consumers, employers, payers pharmas
22. 22
Timely
•Analyze compliance data
ahead of time to highlight
problems before submission
Streamlined
•Easier to locate, access and
report; new reports can be
added quickly to increase
regulatory adherence
Actionable
•Provide further drilldowns to
identify root-causes in order to
take actions to rectify the issues
Compliance Streamlining
23. 23
Transform readily available, everyday data into actionable knowledge
Healthcare Payer Medical Informatics
Eligibility
– Clinical expertise
– Statistical tools
– Data mining
– Predictive analytics
– Research methods
– Database
technologies
– Published papers
Optimize
Quality
Medical
Inpatient &
Outpatient
Pharmacy
Data Sources
(Structured and
Unstructured)
Labs
Demographics
Medical
Records
Surveys
Health Risk
Assessments
Seamless
Information
Exchange
Enhance
Collaborative
Care
Cost
Containment
Enhance
Health
Outcomes
Population
Health
Analysis
Prevent
Fraud
Medical
Informatics
Possible Actions
to Take
24. 24
Predictive Modeling
Turning Data into Knowledge – Example
We have
35,000
individuals in
our population
with diabetes.
The patients cost
us $7,000 this
year, a 15%
increase over
last year.
The national
prevalence rate
for diabetes is
8.3%; ours is
12%.
Hypertension is
a major co-
morbidity for
diabetes.
Assign patient-
level risk scores
using a statistical
model to predict
which diabetics
will be
hospitalized next
year.
Efficiently
allocate care
management
resources to help
reduce
avoidable
hospitalizations
for at-risk
patients.
Wisdom
–actionable
info
5
Knowledge
–goals
–targets
4
Information
–benchmarks
–trends
3
Secondary
Data
–averages
–rates
2
Primary Data
–counts
–sums
1
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Turning Data into Knowledge – Examples
Wisdom
(actionable info)
5Knowledge
(goals, targets)
4Information
(benchmarks, trends)
3Secondary Data
(averages, rates)
2Primary Data
(counts, sums)
1
A total of 10,000
Medicaid enrollees
received mental health
services in SFY 2010.
We have 35,000
individuals in our
population with
diabetes.
Medicare patients
cared for by our
physicians have an
average cost of $8800
per year.
The procedure for
internal fetal monitoring
was billed multiple times
for the same pregnancy.
Mental health services
expenditures averaged
$400 pmpm in 2009.
The patients cost us
$7,000 this year, a
15% increase over last
year.
The No. 1 DRG for our
hospitalized Medicare
patients is chronic heart
failure.
This amount has
increased by 2% in
each of the past three
years.
Payments for mental
health services to
provider X have risen
20% YOY whereas the
Statewide average is
5%.
The national prevalence
rate for diabetes is
8.3%; ours is 12%.
Hypertension is a major
co-morbidity for
diabetes.
The number of heart
failure patients
compared to benchmark
data is high.
This is not medically
justified as the
procedure is only
performed during active
labor to monitor fetal
heart rate and uterine
activity.
Applying data mining to
large data sets, we can
automatically detect
more fraudulent
providers and increase
our ROI.
Assign patient-level risk
scores using a statistical
model to predict which
diabetics will be
hospitalized next year.
Medicare patients with
Class 4 heart failure
without a cardiac
specialist cost over
$50,000.
This procedure was
controlled solely by
diagnosis, which did not
prevent misuse and
coding errors.
We will proactively
ward off complex sets of
fraudulent claims using
predictive analytics.
Efficiently allocate care
management resources
to help reduce
avoidable
hospitalizations for at-
risk patients.
Early referral to a
“Heart Failure Specialty
Clinic” may lower the
Medicare cost profile.
Update medical policy
to reimburse fetal
internal monitoring in an
inpatient setting and
establish limits for
reimbursement
consistency.
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26. 26
Client A Client B Client C
Use Cases
– Client concern
• Vendor proposes device for
chronic wound care claiming
substantial cost effectiveness
• Need to due diligence
– We researches
• Device
• Medical literature for wound
care
• Develops assessment study
– Our study reveals
• potential for significant savings
based on prevalence of wounds
– We recommends
• Pilot of new treatment
– Client concern
• Is mental health utilization
below norms?
• If so, what financial penalty risk
– We examines
• HEDIS methods
• Reviews medical literature for
benchmarks
– We executes study
• co-morbidities
• utilization trends
• confidence intervals
– Our study reveals
• Client in full compliance
• At national norms
• No penalties incurred
– Client concern
• Children receiving dangerous
and costly anti-psychotic drugs
with no evidence of approved
diagnosis
– Our study reveals
• Similar disturbing patterns
– We recommends
• Physician education,
• Care management for patients
• Consideration for a prior
authorization program
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