As healthcare organizations ramp up their shift to value-based care, hospitals and health systems are looking to follow through on its promise: better care for patients, more efficient operations, and more revenue to sustain their work. For provider organizations in particular, knowledge is power when it comes to taking on risk and maximizing value-based care contracts. That’s why claims data integration is foundational to this work: Without it, hospitals and health systems are missing key opportunities for the downstream analysis needed to capture the value in value-based care.
In this two-part series, we’re exploring these key opportunities—so that hospitals and health systems truly understand the analysis that they’re leaving on the table if their claims data isn’t in order. We’re also sharing some of the key insights we’ve learned about claims data along the way, from decades of experience of providing analytically-ready datasets to clients.
Missed Opportunity #1: Leveraging claims data for HEDIS measures
HEDIS measures often serve as the basis for evaluation of quality incentive programs and related payments, so it is essential for providers to be able to measure, report, and develop strategies to improve these scores. Providers who have ongoing insight into their HEDIS performance will have an advantage in demonstrating their value to payers, prospectively for initial contract negotiation and during the term of their risk contracts.
As claims data is the primary source of data to calculate HEDIS measures, having a comprehensive, reliable, and continuously updated claims dataset is critical—not only for calculations today, but also to provide a foundation for future analysis. That is, as quality metrics mature and evolve beyond pure HEDIS measures, and as HEDIS measures are modified and expanded, having a robust claims dataset ensures that providers will have the ability to evaluate their performance on whatever measure is proposed by the payers in the near or long term.
The HDI perspective: Correctly tracking your attributed population, their eligibility status with the payer over time, and their historical and current utilization and costs is critical for accurate measure calculation. There are many nuances to leveraging claims data for HEDIS reporting. For example, most measures have very specific requirements around eligibility, specifically related to the definition of the denominators and exclusions in the numerators. Continuous enrollment can be tricky to calculate if eligibility files are not managed carefully. HDI helps your team navigate these nuances to optimize downstream analytics.
Missed Opportunity #2: Leveraging claims data to close care gaps
Care gaps show discrepancies between best practices and actual care and are clearly significant for both the delivery of optimal care and the associated financial penalties that may be linked to them in the VBC contracts. VBC contracts generally reward providers for closing care gaps and penalize those who don’t.
In addition to identifying care gaps, providers need to understand the root causes of those gaps. For instance, do gaps exist because of:
- Poor care coordination?
- Insufficient patient outreach and engagement?
- Provider education?
- Patient non-compliance?
Identification of root causes empowers providers to create strategies and solutions to address these gaps. Providers who have ongoing insight into their care gap performance will have an advantage in demonstrating their value to payers, prospectively for initial contract negotiation and during the term of their risk contracts, where care gaps impact payments to providers. Claims data analysis allows providers to be proactive in ensuring gap related compliance, particularly for chronic conditions.
As claims data is the primary source of data to identify care gaps, having a comprehensive, reliable and continuously updated claims dataset is a necessary prerequisite.
The HDI Perspective: HDI develops analytically ready datasets that can be used as input to care gap algorithms. The existence of a complete, validated claims dataset will ensure that the algorithms are not hampered by incorrectly identified gaps due to poor data, and are most likely to identify closed gaps appropriately.
Missed Opportunity #3: Leveraging claims data for network analysis and provider performance
Working with a comprehensive claims dataset provides insights and opportunities that would not be possible using clinical data alone. In the context of network performance, claims data can be used to:
- Identify network leakage and assess network adequacy: When members seek care outside of a preferred network, it can adversely impact control over care delivery and costs. Reasons for leakage need to be understood and addressed.
- Identify best practices and evaluate provider performance: Claims data, particularly when integrated with clinical data, allows for the analysis of efficiency and quality of care, specifically around common episodes. It can be used to determine the best practices of the highest performing providers and to determine provider reimbursements to reward for high performance.
- Analyze referral patterns: Claims data can be used to identify patient flows within and outside of the network. In conjunction with best practice analyses, a health system can refine and improve their network.
- Plan for future network expansion: Understanding underlying utilization patterns of a population and projecting that to growing and changing populations allows for thoughtful development of networks.
The HDI Perspective: Analyzing network performance, specifically related to network adequacy, out of network utilization and provider financial and clinical performance requires a database that can be confidently queried and used to drive data-based decisions. HDI’s core model, along with its comprehensive data validation process, ensures that this data is available in a consistent and usable format. Data Integration with clinical data significantly increases the power of this type of analysis.
Only when the underlying data is clean, complete, and organized can hospitals and health systems achieve true visibility into their performance. And conversely, if hospitals and health systems are not paying attention to the nuances of claims data integration, they are missing out on success in these key areas of VBC. Read Part 2 of our series here.
