Premera Blue Cross Combines Claims and Clinical Data to Improve Care and Business Performance
Health plans have long operated using only retrospective claims data for making business and care decisions. But with the ongoing transition from fee-for-service to value-based care, claims data is no longer sufficient. Forward looking health plans need a near real-time view into the health and care of their members, and into their own performance.
Premera, a not-for-profit licensee of the Blue Cross Blue Shield Association operating in Alaska and Washington State, has found an innovative, efficient, and cost-effective solution to this challenge.
Innovating with Claims and Clinical Data, Together
Premera chose InterSystems HealthShare® to bring together clinical data from health information exchanges, provider group electronic medical records (EMRs), and claims to build a complete picture of each of its members. Now, Premera can more effectively manage risk and utilize data to support its mission of “improving customers’ lives by making healthcare work better.”
Premera began working with HealthShare in 2017. “We were up and running quickly,” says Colt Courtright, Director of Corporate Data and Analytics at Premera. “Within 120 days after signing the contract with InterSystems, we connected to the Alaska health information exchange and used HealthShare to aggregate and normalize 150,000 patient records from across the state.” Premera then expanded use of HealthShare to its Washington-based customers, and then to over 1 million contracted customers living in other states. Premera now combines claims data with the real-time alerts and other information it receives from more than 400 EMRs used across this population.
A Caring Health Plan, Closer to Patients and Providers
“Having real-time clinical data, like that coming from admission, discharge, and transfer and emergency department feeds, gives us greater awareness of cost and quality decisions on the part of our customers,” says Courtright. “In Alaska, for example, if a member is going to see a specialist, we’re aware of that, and we can find one who’s close to the customer and with lower out-of-pocket costs. And if we see they haven’t seen their primary care provider in three years, we can talk to them about that and make sure they get the care that they should.”
Combining claims and clinical data gives Premera timely insight into its customers’ care, and that insight can be shared with providers. “Does the doctor know that the prescription hasn’t been filled?” asks Courtright. “Does the primary care provider know if the patient is seeing three other doctors, or goes to the emergency room? We’re able to close gaps in care and give doctors a much more complete picture of their patients’ health, empowering a richer care experience.”
Complete Data for Healing a Fragmented Health System
Premera’s integration of claims and clinical data solves many of the problems inherent in a fragmented healthcare system, and also gives Premera an advantage in improving its own business processes and performance.
“As a payer we’re used to having data in neat columns and rows,” Courtright explains. “But clinical data isn’t like that. We use HealthShare to bring in clinical data, and are working to use natural language processing and analytics to improve HEDIS health quality scores and find coding gaps that we couldn’t see using claims data alone.” This process will help Premera find nuances in the clinical data indicating that a patient should be classified as a higher-risk diabetic or cardiac patient, for example. “The physician caring for the patient over time may not have fully captured the coding,” says Courtright. “Catching these discrepancies and making commercial risk adjustments assures market stability for health plans like ours covering high-risk patients.”
Improved Vision, Seeing the Future for Health Plans
Using HealthShare, Premera is able to see deeper and more accurately into the health status of its customers, into what its providers need to improve care, and how the business can improve. “We can solve the problems of our current healthcare system by working together across the provider and payer community using InterSystems solutions,” notes Courtright. “Health plans need to support modern technology like HealthShare. We believe that reducing waste and streamlining processes improves care and reduces costs for our customers.”