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Data Revolution: When Claims and Clinical Data Meet

January 31, 2014
by David Raths
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For years now, large integrated health systems such as Oakland, Calif.-based Kaiser Permanente and Intermountain Healthcare in Salt Lake City have been combining clinical and claims data for population health analytics. In today’s era of health reform, with many providers taking on more risk, even health systems without provider-sponsored health plans are starting to integrate payer data.

One example is Carolinas HealthCare System in Charlotte, N.C., which is taking advantage of one of Verisk Health’s population management solutions in Premier’s PopulationAdvisor suite, which manages and analyzes both claims and clinical information to help providers make better financial, operational and clinical decisions.

It is still unusual for a provider that is not part of an integrated system to be able to combine claims data and clinical data, notes Michael Dulin, M.D., Ph.D., medical officer for analytics and outcomes at Carolinas. “We are trying to understand the total picture with our patients across a spectrum of care,” he explains. “As a large health system, we do capture a lot of that in our network from primary care to the hospital setting. But still, we want to know what happens when our patients go to emergency rooms outside our network or while traveling. Some provider organizations are payers themselves, but our thinking is that through a partnership with the payers, we can get a better picture of the total cost of care and get a 360-degree view of the patient.”

Michael Dulin, M.D., Ph.D.

Carolinas negotiates with commercial payers such as Aetna to share this data, Dulin says, and his team is working on a grant proposal to request Medicare data for these same purposes.

Dulin says providers often get regular reminder letters from multiple payers. “They might say you have five patients covered by our company with reminders about screenings or other best practices. That is helpful, but these paper notices from multiple companies are difficult to coordinate with workflows,” he says. “What we are doing is getting all that information together in one place and at the point of care in a decision support tool. We are taking our own clinical data and matching it with the claims data under a single interface. The hope is that it will drive down unnecessary tests, such as mammograms, if the provider can see that one has been ordered outside the network.  And they can see whether a patient has actually filled a prescription.”

The most important aspect to the payers, Dulin explains, is to help Carolinas bring costs down and improve care. “I think it is a win-win if we can avoid redundant testing and variability in care,” he adds.

Keith Figlioli, senior vice president of healthcare informatics for the Charlotte, N.C.-based Premier Healthcare Alliance, says it is critical to pull claims and clinical data together. “The data the payers have is a mile wide but an inch deep. The providers’ data is deep but narrow. You need the nexus of the two.”

Keith Figlioli


Although data-sharing between payers and providers is on the increase, there is still tension in the relationship. “The single biggest challenge in negotiating agreements on new types of contracts is who has access to what data, and there is something of a data grab under way,” Figlioli says.

“We have concerns about giving the data to payers, because then the payers are controlling the care processes. I think that for the population health component, where you are getting paid for outcomes, you should control the data repository.” He says his organization counsels its provider organization members that they should own their own data warehouse and analysis infrastructure. (Premier has an enterprise data warehouse offering in the cloud for members.)

One physician executive who agrees with Figlioli is Scott Hines, M.D., co-chief clinical transformation officer for Crystal Run Healthcare, a multispecialty physician organization in the mid-Hudson Valley of New York that is one of the fastest growing accountable care organizations (ACOs) in the country. “You don’t want to be at the mercy of trusting data that is provided to you. You need the ability to do the analyses yourself,” he says. Crystal Run has a business intelligence team of six and has created its own tools to gather data on 70 quality measures.

SIDEBAR: A Joint Effort Focused on Big Data, Research

Most of the efforts to join clinical and claims data involve pay-for-performance contracts between payers and providers. But the health services organization Optum, a subsidiary of UnitedHealthcare Group which is also the parent of payer UnitedHealthcare, founded Optum Labs in 2013 as an open collaboration center. Initially working with Mayo Clinic, Optum Labs, based in Cambridge, Mass., is expanding to include other stakeholders across the ecosystem of payers, providers, academics, life science companies, and consumer organizations. “All have an interest in improving the delivery and value of patient care,” says Paul Bleicher, M.D., Ph.D., CEO of Optum Labs.

Both Mayo and Optum realized that they had substantial amounts of data, but many participants in the healthcare system don’t have access to this type of data. “By combining this data and involving other providers in the ecosystem, such as medical device companies, we can create cross-industry organizations that wouldn’t normally work together,” says Bleicher, who was formerly chief medical officer for Humedica, a clinical informatics company that was acquired by Optum in January 2013.