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Data Revolution: When Claims and Clinical Data Meet

January 31, 2014
by David Raths
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Birkmeyer co-founded a company called ArborMetrix that is helping MVC with its analytics. Its CEO, Brett Furst, explains that with more risk being put on providers in pay for performance contracts, there is an underserved need for analysis of episodic care in the acute setting. “What we go after is that clinically granular data in acute and specialty settings,” he says. “With just billing data, it doesn’t do much good to determine that one health system charges 10 percent more than another for a specific type of care,” he explains. “Without the clinical data, you can’t address the why. Maybe the outcome is better. But for some ACOs, we are seeing two providers that are $25,000 apart on some episodes of care and the lower cost provider is reporting better outcomes.”

Brett Furst

Keith Blankenship, vice president of technical solutions at St. Louis-based Lumeris, a healthcare consulting and software services firm, agrees that some efforts at clinical quality improvement that involve only claims data struggle. “We worked with one group that wanted to highlight uncontrolled hypertension. But without the clinical data, they couldn’t identify uncontrolled hypertension,” he says, “so they had to wait until they had both types of data in the system.”

Lumeris offers a cloud-based delivery system that pulls together EHR and claims data, and has a master patient index and analytics tools.
Blankenship adds that now that payers and provides are sharing data more frequently, they are gaining a better understanding of how powerful the combination can be. “Our platform supports multi-payer models driven by providers,” he says. “Then it becomes like a matrix, where the provider sees his or her own whole panel, but each payer sees just its customers’ data.”

Baptist Memorial Health Care in Memphis, Tenn., is working on a coordinated care initiative that involves incorporating claims data from Aetna with the data in its Epic EHR.

Previously, physicians had localized data on the patient: whether they kept an appointment or were admitted to the hospital, but they had no view beyond that outside their four walls, explains Paul DePriest, M.D., chief medical officer for Baptist Memorial. “The data from Aetna can give us a global view for a population.”

In the past, Aetna would send out letters to physician offices with reminders about their members, and so would other insurers, but physicians might not have been able to deal with that information in a structured way, explains Bob Kropp, M.D., regional medical director, accountable care solutions, for Aetna. “Now with EHRs, re-engineered work flows and care coordinators in physician offices, doctors are finding efficient ways to use the data, and they are seeing the value and validity of it.”

Clinicians have traditionally chafed at having data sets presented to them, DePriest adds, “but there is more potential value in having the data in clinical decision support tools sitting on top of Epic to remind them about high-risk patients.”

SIDEBAR: Analytics Tools to Collaborate on Claims Administration

Analytics can help improve care delivery, but it can also help with the main point of contention between payers and providers: claims administration.
When Juan Davila, executive vice president, healthcare quality and affordability, first came to Blue Shield of California in 2006, he saw right away that relationships with providers were terrible. “It is an industry-wide problem,” he says. “There is a disconnect and it is an adversarial relationship with lots of finger pointing. We would go into meetings and providers would say, ‘We have $10 million in claims you owe us and haven’t paid.’”

To address this problem, Blue Shield worked with performance management company MedeAnalytics (Emeryville, Calif.) to create a web-based tool where providers could look at the raw claims data. “This opened the kimono and gave them both the data and slice-and-dice capabilities to get at the root of the problems,” Davila says.

Today, every hospital in the state is participating in what Blue Shield dubbed the Partnership in Operational Excellence and Transparency (POET). Quite often, Davila says, claims are denied or delayed because data is coded the wrong way. “It is mistakes that both the hospitals and insurers make. I consider that waste, and it is fixable,” Davila says. Using the tool, Mission Hospital in Mission Viejo went from 30 percent denials to the low double digits, he adds.

“This is about transparency,” Davila says. “We can both look at and improve our processes. And it is not just based on anecdotes. It gets the emotions out of the way. These partnerships help lay the groundwork for ACO work.

Davila says the POET team’s work is never really done. “We have ICD-10 going in and the POET team will have to work on the coding differences for that. “This is a tool that allows for dialogue,” he says, “and we have to keep that dialogue going.”