What Big D ata S hould D o for You: Requirements to Support Population Health

1. What Big Data Should Do for You: Requirements to Support Population Health HFMA West Virginia Chapter September 25, 2014

2. QUALITY & COST SOFTWARE HELATH PLAN SERVICES DATA ANALYTICS STRATEGIC & CLINICAL CONSULTING Valence Health – Lori Fox Ward, RN, BSN • Technology-enabled services since 1996 • National presence with 500 employees, 4 offices • Serve IDNs, IPAs, PHOs, ACOs • Serve 39,000 physicians, 120+ hospitals • Support nearly 20 million patients • Privately held • 47% financial growth year over year Accountable Care Clinical Integration Population Health • Senior Vice President of Strategic Initiatives • 20 plus years of experience in the managed care industry working with providers and health plans • Leads implementation of population health management programs for numerous provider organizations

3. Objectives

4. ACA is Providing Incentives for Physicians and Hospitals to Align for Common Goals Pre-ACA Implementation1 Post-ACA Implementation3 • Bundled payments • Shared savings / risk arrangements • Must manage care together • Safe harbor for physicians and hospitals to operate Lack of Shared Incentives Aligned Incentives • Long term contracts offered with no productivity terms or quality incentives $ • Penalties for poor quality scores for hospitals • Staying on top of quality scores means improving physician relationships Lack of Physician Governance Demand for Coordinated Care • Physicians were promised a greater say that was never delivered Fragmented Structure Technology Incentives2 • Meaningful Use initiatives provide incentives for investment in technology that improves coordination • Overcome data issues • Hospitals failed to organize multiple physician groups into a cohesive units • Lack of communication tools Deloitte Center for Health Solutions. “Physician-hospital employment: This time it’s different.” 2013. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd Centers for Medicare & Medicaid Services. 2014 Definition of Stage 1 of Meaningful Use. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html PwC Health Research Institute. “From courtship to marriage: A two part series on physician-hospital alignment.” 2011. http://thehill.com/images/stories/blogs/pwc%20trust.pdf

5. Healthcare Delivery Implications are Inherent with these New Alignments Trends are combining to create a fundamental shift in how we deliver and pay for healthcare services.

6. A Range of Technology Solutions May Be Enabled Business Requirements

7. What Makes “Big Data” Big in Healthcare • BIG DATA: DATA ELEMENT EXAMPLES DATA ARCHITECTURE External Data Internal Data • Small scale personal health records • Insurance data STRUCTURED DATA CLASSIC HIGH VOLUME • Treatment data • Procedure data • Research data UNSTRUCTURED DATA Extract, TransformLoad HIGH VELOCITY • App & personal monitoring devices • Telehealth information SENSOR DATA EMERGING HIGH VARIABILITY ANALYTICS • National electronic health records • Scans, images, videos, #tweets NEW DATA TYPES

8. Objectives

9. Big Data’s Ultimate Healthcare Objective: Effective Population Health Management Key Questions to Inform Population Health Strategic Goals Which populations? What desired health outcomes? What cost-of-care targets? • Children ages 6 to 10 in zip codes 60662, 60607, 60615, and 60609 • Increase asthma control by 50% • Enable 100% of patients to self-manage via Asthma Control Plan • Reduce emergent ER/ED visits for acute asthmatic episodes by 30% EXAMPLE • Supported and Validated by Population Health Analytics Enabled by Big Data Applications

10. In Population Health, Timeliness, Precision and Comprehensiveness Matter COMPARE: What Information a Physician Obtains from Different Data Sources Timeliness and precision ADDITIVE BENEFITS: Comprehensiveness

11. Key Functions to Support a Population Health Program 1 2 3 4 The following resources are necessary to meet functionality requirements: Technology Resources Data • Timely integration of quality and cost data • Data governance • Nimble environment • Business intelligence capability • Skilled analysts • Technical support • Dashboards • Alerts • Data mining • Easy distribution • Standard reporting • Advanced analytics

12. At the Core of Population Health is the Ability to Capture, Aggregate, and Act on Clinical Information 1 2 Clinical engine 3 4 IT = Information Technology, EMR = Electronic Medical Record, FTC = Federal Trade Commission

13. Attribution and Member Matching are Key to Data Integration in Population Health Attribution Member Matching • Attribution is key to creating joint accountability for risk and quality. Configuration can be based on: • Provider type: specialty type, PCP, PCP subtypes • Single or multiple attribution: including groups as defined by geography or specialty • By encounter detail: counts, types, and diagnoses specific • Configurable at the measure level • Any permutation of the above • Member matching capabilities reliably and accurately link unique individuals across EMRs, PMS, labs, Rx data, professional services, hospitals, and other institutions. Algorithms are: • Tuned to enhance specificity and avoid false negatives • High matching rates with capabilities for manual clinician directed merging • Incorporate advanced statistical methodologies including probabilistic matching, Bayesian algorithms, and deterministic logic Attribution assignment can be… • Assigned by the payor or EMR • Based on number and type of E&M codes • Assigned using ranked specialists • Triggered by Dx or Px • More customized, if client wishes

14. Objectives

15. Data Analytic Requirements for Population Health Clinical Financial / Actuarial Provider / Network Management • Patient stratification • Disease & Population management • Population analytics • Care management • Gaps in care • Episode and other groupers • Patient engagement • Trends and predictive modeling • Risk adjustment • Contract performance • IBNR • Pro-forma modeling • Provider efficiency • Quality reporting • Incentive model • Provider scorecards

16. Identify Populations With High Opportunity and the Methods to Manage Them Clinical Analytic Requirements

17. Actionable Population Health Requires Timely Insights at the Administrative, Practice, and Physician Levels Track Admissions and Readmissions Track Performance by Physician Track Post-Discharge Follow-up # of patients % Met overall % Met 14d visit % Met Card visit Jones, Martha Peters, Anne CHF post discharge follow-up by physician 2 CHF admits in 2012, but no outpatient visits? Track Admissions and Readmissions Actively Track Patients with Overdue Care Tonks, Fred Day, Camile Schwartz, Saddie 7 CHF admits, 2 readmits <30d Globally or individually perform expedited outreach

18. Provider and Network Analytics Provide the Quality and Cost Transparency to Effect Change Provider / Network Analytic Requirements

19. Provider Efficiency Reports Identify Outlier Performers

20. Quality Reporting Provides Network Performance Comparisons Quality Measures Module Desired Attributes for Quality Reporting • Includes meaningful indicators of quality • Attributes patients to physicians in a way that I trust • Enables users to understand & improve the quality of care provided to patients • Sufficiently incorporates benchmarks & targets • Provides intuitive and actionable reports & dashboards • Allows users to drill down easily & sufficiently • Compares performances across providers/practices in a valid manner • Will allow my organization to display its value-based business case (i.e. organizational performance) Physician Drill Down Capability

21. Using Data to Evaluate Overall Performance Financial / Actuarial Analytic Requirements

22. Performance Insights into the Cost and Quality of Care • Manage value-based contracts • Attribute / allocate costs in a meaningful way • Understand and optimize cost-effectiveness of care provided to patients • Compare cost over time vs. cohorts vs. benchmarks • Analyze medical costs and trends • Compare cost over time vs. cohorts vs. benchmarks • Understand and optimize the utilization of healthcare services within the network • Avoid unnecessary cost and utilization (i.e. duplicative tests, services, etc.) • Track medical expense across major expense categories • Catastrophic claims • Medical claims distribution • Profile physician performance on cost and utilization • Profile practice performance on cost and utilization

23. Data is Only One Piece of the Puzzle • Population Health Management Requires • Dedication to Daily Operational Excellence • Data capture • Cross-continuum, evidence based practices • Access to care • Clinical quality and resource utilization Care Delivery Management ONGOING ANALYSIS AND PROGRAM REFINEMENT Policy • Definition of population and determinants of health • Uniformly defined quality standards • Communication • Health promotion and prevention • Equalization of access, outcomes, cost • Program development • Analytics • Reporting and tracking • Risk alignment and mitigation • Continuous communication of quality

24. Thank You for Your Time Today • Medical Cost & Utilization • Risk Adjustment For additional questions and comments, please contact Lori Fox Ward at LFox@valencehealth.com vQuest Health Plan Services • Claims Processing • Premium Billing • Provider Portal • Member Portal • Clinical Integration • Quality Measures • Population Health for Multi-TIN Settings • Registries Vision Population Health Management Solutions Care Manager • Case Management • Care Coordination • Patient Outreach