Opportunity for Payers – There’s clinical data out there that you may need, but don’t know it

My colleagues and I recently hosted a breakfast roundtable at the AHIP – National Conferences on Medicare, Medicaid & Duals in Washington, DC. The goal of our roundtable, “Rethinking Your Clinical Data Strategy to Boost Quality, Improve Outcomes and Deliver Value,” was to get people from Managed Care Organizations (MCOs) talking about their strategies for how to use clinical data as their organizations shift to new models of payment and care.

Based on trends observed both in the market and with our clients, we broke the audience up into four groups to discuss the following topics in more depth.

  • Enhancing and streamlining quality measurement and closing gaps in care
  • Improving care coordination through alerting and use of a shared care plan
  • Enhancing the performance of your provider network
  • Streamlining operational efficiency

Each group reiterated that there are opportunities for health plans to use clinical data to provide value to their members, provider network, employers, and hence, their organizations. Some of the top use cases discussed included automating prior authorization, automating chart reviews, using pharmacy data to manage medication adherence, and fraud detection.

One of the areas that has always interested me was how to automate the HEDIS™ measurement process. It is lengthy, time- and resource-consuming, and ultimately retrospective. I often referred to it as the “chart chase.” Furthermore, given that there are now a plethora of new quality measures based on clinical data, isn’t it time we made use of that body of work to improve the process for hybrid HEDIS measure calculation? Some of our clients have already started to solve this problem.

For example, a very common measure is controlling high blood pressure. Claims can tell you if the patient had a diagnosis of hypertension within the measurement period. That’s what claims do really well: identify an event. However, to determine if that patient’s blood pressure was controlled involves one of the following manual processes: an onsite visit to perhaps multiple sites of care, and then reviewing the chart; remote access to the chart with permission; or having the provider upload or fax the relevant information to a portal. What if the health plan had access to the clinical data and could review the value real time to inform the calculation? Not only would the health plan and the provider have current information about how they are performing on a measure, they can intervene if they see the trend going up and down.

Working with the provider network in this way also reinforces that quality improvement benefits everyone. The good news is that some of our clients are already doing this through use of our connected health platform, HealthShare, to access data from the providers in their network.

Another area ripe for automation is the medical prior-authorization process. How does a provider or hospital provide clinically relevant information to a payer when requesting an authorization for medical services? A couple of our clients have already tackled that problem. One of our clients developed a solution, currently in pilot stage that uses our technology to automate the prior-authorization process. Early indicators show that this helps save time for both the provider and the payer. Another client plans to use Admission Discharge Transfer (ADT) alerts to trigger an authorization request that would be accepted by their care management system to generate an authorization approval.

What these use cases have in common is that they use clinical data to solve an operational problem. There are many more use cases where clinical data used to augment claims data can add immediate value to the patient, provider – and payer.

We think that all health plans should sit down and think through their strategy for augmenting their claims data with clinical data. What we heard from the AHIP session participants is that there is a need, but they need help thinking it through. With value-based payment on the rise, now is the time to consider building out your strategy. We have partnered with a number of customers who have come to realize the value – maybe you should too.

Check out more blog posts from Lynda Rowe

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For Payers, a Clinical Data Strategy is Critical

The Catalyst: Data Analytics and the Evolution of Modern-Day Health Plans

Lynda Rowe

Lynda Rowe is Senior Advisor, Value-Based Systems, for InterSystems. She provides guidance on alternative payment models, public sector, state Medicaid programs, and related areas. She has over 25 years of experience in information technology, mostly in healthcare technology consulting and operations. Follow her on Twitter @Lynda_Rowe.

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