In Part 1 of this series, we explored how hospitals and health systems that aren’t leveraging claims data properly for HEDIS compliance, care gap closure, and network leakage are missing opportunities to maximize their value-based care (VBC) contracts.
In Part 2, we’re diving into three more areas where claims data powers important downstream analysis—as long as the data is clean, complete, and organized, which is a major challenge in and of itself.
Missed Opportunity #4: Leveraging claims data for cost and utilization tracking
Providers operating under VBC agreements need a clear understanding of the cost and utilization patterns that are reflected in their care delivery process.
They can analyze their cost and utilization data to gain significant insights, which should drive strategies in many areas including financial management, clinical operations, performance reporting and contract management.
This data is useful for:
- Identification of high cost diagnoses, providers and patients;
- Trend analysis;
- Network management;
- Quality monitoring and reporting;
- Prospective evaluation of VBC contracts; and
- Performance monitoring of existing contracts.
The HDI perspective: Accurately managing cost and utilization requires confidence in the underlying data, specifically related to the appropriate counting of events. This requires accurate resolution of duplicates, reversals, adjustments and multiple claims for the same event. HDI focuses on developing databases that allow for immediate analysis without having to account for inconsistent vagaries in the way different providers deal with these issues.
Missed Opportunity #5: Leveraging claims data for Population Health Management
Population health management involves improving overall health outcomes in a community within the available financial constraints. From a data perspective, providers seeking to do this need to initially be able to:
- Identify and manage high risk patients;
- Identify gaps in care;
- Understand variances in the quality and costs associated with different treatment options;
- Understand differences in outcomes and costs at the provider level;
- Understand utilization patterns of the covered population; and
- Evaluate the effectiveness of programs aimed at quality improvement and cost savings.
Claims data is key to identifying and evaluating these key components of population health management—and ensuring that internal resources are being allocated for the highest impact per dollar spent.
The HDI Perspective: Population Health Analysis requires the development of a robust, current, complete and validated set of historical claims, membership and attribution data. This data serves as an essential resource for providers seeking to maximize their performance in managing population health on their covered population. HDI’s expertise in developing these analytic ready datasets allows providers to focus on the associated analytics without having to worry about the integrity of the underlying data.
Missed Opportunity #6: Leveraging claims data to maximize VBC contracts
VBC contracts link the risk-portion of provider payment to key measures, including utilization, cost, quality and other performance measures.
It is critical for providers to be aware of their performance relative to all these measures, to ensure that any areas of poor performance can be identified and addressed quickly.
It is also critical to be fully comfortable with all these indicators during the contract renewal and re-negotiation stages to ensure the most favorable contract terms based on full knowledge of the organization’s performance capabilities.
Payers with this visibility to their performance can be more strategic about what’s included in their payer contracts, understand how they’re helping payers achieve compliance goals, identify opportunities for more revenue, and manage downside risk by understanding where their patient outcomes are lacking or their costs are too high.
The HDI Perspective: Analysis of performance under VBC contracts requires confidence in the underlying data to ensure that measures associated with upside and downside risk can be accurately measured during the term of the contract. Providers should have complete confidence in their analytic data before making any strategic or operational changes based on what they see in the data. HDI’s expertise in developing these analytic ready datasets allows providers to focus on the associated analytics without having to worry about the integrity of the underlying data.
At the end of the day, analytics departments at health systems have plenty on their plates when it comes to reporting on all of these key pillars for value-based care. These opportunities are often missed not because providers don’t believe they’re important, but because the underlying claims data is holding them back. Providers who want to put their best foot forward in today’s value-based care landscape can begin by improving their claims data integration—thereby setting up their analytics teams, and organizations as a whole, up for success.
Want to learn more about how HDI can give you more confidence in your claims data? Contact us today.
