Targeting Chronic Illness Together

In the fall of 2010, Tufts began sharing the data with 100 provider entities. Only a small number are NCQA-certified medical homes, but that number is increasing. For the most part, the response from physicians has been positive, Harding says. “Some were doing similar things on their own and stopped because they liked our list,” he says. “Some complain about the three- or four-month time lag. They want to get upstream of that. But we can only give them what we have. They have to supplement that with their own data that is more current.”

QualChoice, a small health plan in Arkansas that had been hospital-owned but is now independent, is piloting a patient-centered medical home, and the idea is to get the primary care providers information about their patient population before they reach the stage of being catastrophic, says Richard Armstrong, M.D., the plan’s vice president of medical affairs. QualChoice is just starting to use Clinical CareAdvance, a solution from the Denver-based TriZetto Group, which allows payers to manage members who have chronic diseases by coordinating resources, automating manual processes, and identifying and stratifying at-risk members for support across the care continuum.

But for any of these tools to help clinicians, Armstrong believes, the flow of data between payers and providers has to improve. “For ACOs to flourish, they need to be able to do analyses and have actionable data,” he explains. “The reason capitation didn’t work before is because we just threw the money over the wall and said good luck. The providers couldn’t analyze how they were doing.” Payers have always had better health IT infrastructure for doing analyses, he adds. The trick is to figure out how to put it to use for clinical purposes.

TriZetto’s payer clients are still in the early stages of using these clinical analytics tools, says Jerry Osband, M.D., vice president of product management at The TriZetto Group Inc. “What we found in the past was that different parts of payer organizations had different business intelligence needs, so we might find one payer organization with five or six different analytics vendors,” he notes. “Now they are starting to aggregate that data in a data warehouse and reducing the number of vendors they work with to one or two.”

Those payers who used to focus on individual claims are now looking across their entire membership to better define the appropriate level of financial risk to assign and to drive the right kinds of interventions, he says. “They can reach down to patients at lower levels of acuity,” Osband says, “and plan mitigations that will help prevent members from poor and expensive outcomes.”

Analytics for Wellness Programs
One integrated health system used its own employees in a test to see whether predictive analytics could have an impact on its wellness and disease management efforts.

Starting in 2007, Optima Health, the insurance arm of Sentara Healthcare in Norfolk, Va., used Risk Navigator analytics from the Orlando-based Elsevier/MEDai to support Sentara employees with customized prevention programs.

Karen Bray, Ph.D., R.N., vice president of clinical care services for Optima, reports that the “Mission Health” program both improved awareness and treatment of health risks such as high blood pressure and high cholesterol and bent the cost curve.

Karen Bray, Ph.D., R.N.

Optima officials created their own risk models. “We looked around the industry and didn’t really see a blueprint,” Bray says. “We took the claims and lab data we had access to and ran a bunch of what-if scenarios, and that allowed us to create some of the parameters and definitions for the program.”

Optima found that three conditions accounted for 14 percent of its costs: diabetes, coronary artery disease, and congestive heart failure. Employees identified as being at risk for such conditions received incentives of up to $600 per year for reducing health risks and complying with evidence-based guidelines. The employees worked with nurse case managers and health coaches.

By 2009 the program paid for itself and by 2010 Sentara saw $3.4 million in healthcare cost savings, Bray says. Since then, the program has been expanded to six or seven large employer groups in the area representing about 90,000 members.

Now Optima is using the analytics to show physician groups interested in becoming patient-centered medical homes some of the gaps in care they can address with Optima members. “Physician groups are doing a good job,” Bray says, “but once you pull the data apart, you can see where gaps in care are and reinforce the changes the physicians are making to their practices.”