ppcs episode 360 solution white paper
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8/4/2019 PPCs Episode 360 Solution White Paper
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1760 Old Meadow Road, McLean, Virginia 22102
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www.ppc.com 1
aced with fast-paced changes in the health care market landscape, a dynamic regulatory
environment, and ever increasing competition, the managed health care sector is constantly
looking to increase competitiveness, reduce costs, and deliver better patient care.
While Managed Care Organizations (MCOs) strive for sustainable competitive advantage, IT can play a
very important role in their overall strategy for achieving it. MCOs have long understood the potential
value locked up in the data they routinely collect and store. However many factors have kept them from
harnessing the complete value of this data. These include:
Lack of data integration across multiple heterogeneous systems (claims, laboratories,
pharmacy systems)
Tedious management reporting process that may require numerous iterations to produce even
simple reports
Lack of timely access to data required for operational and strategic decision making
In addition to impeding operations, lack of this data also affects consumer-focused sales and marketing
efforts. To sum it up, a fragmented IT system impedes decision making for both operational and strategic
purposes.
How can this diverse data, in multiple systems be integrated and used to make health care organizations
more competitive? Bringing together the various pieces of data around ‘Episode of Care’ presents onesuch opportunity.
What is an Episode of Care (EOC)?An Episode of Care (EOC) can be defined as the set of services required to manage a specific medical
condition of a patient over a defined period of time1. For example, in the case of a tonsillectomy
procedure, an EOC would include the pre-surgical evaluation; the actual surgery; the anesthesiologist;
the operating room; pathologist; the operating room team; and follow-up visits to the ear, nose, and throat
specialist and primary care physician, all bundled together for a single price.
EOC is increasingly proving to be a more accurate and holistic approach to estimating the cost of health
care1
. To be competitive in the marketplace, a health care organization’s operational data must contain acomplete, i.e., 360 degree view, of all occurrences associated with an episode of care.
1Shreeve, Scott, “Episodes of Care: You have g ot to be kidding,” May 27, 2008 (http://blog.crossoverhealth.com/2008/05/27/episodes-of-care-you-have-got-
to-be-kidding)
F
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Why is EOC Useful?The traditional fee for service (FFS) approach uses measurement based on population measures, such
as absolute counts, or averages. For example, the number of times a practitioner prescribed antibiotics,
the average number across patients, across number of visits, etc. However, this approach lacks clinicalcorrelation. Based simply on population measures, it cannot be convincingly ascertained that one
physician prescribes more antibiotics than another does. Any assessment of appropriateness needs to
look into individual episodes. Moreover, the above approach creates practitioner distrust.
An EOC-based approach allows for better clinical correlation. For example, the use of azithromycin is
appropriate in a case of pneumonia, but is an overuse if prescribed for a chest cold. The use of antibiotics
per episode (an EOC-based measure) is a much more accurate measure than the average antibiotics
usage across patient population (a traditional population-based measure.)
In addition, an EOC-based approach allows providers and payers to better estimate the cost of health
care delivery by allowing charges to be based on categories of episodes – also called Episode Treatment
Groups (ETG). Since a finer grain of data is used, the risk estimation techniques also yield better results.EOC is a step towards the overall goal of improving quality of health care that can be achieved by
reducing overuse, underuse, and misuse.2
The concepts of EOC are relatively new, and the idea of reimbursing for care in this way is picking up
momentum. This is an important ideological transition, moving from providing ‘fee for service’, ‘pay for
procedure’ mentality to a more comprehensive, holistic approach to delivering care. It also is a very
important enabler towards the eventual state of a retail health market and organizing health care into a
service-based “product” that consumers can compare, shop, and purchase. While that market-state is far
out in the future, implementation of EOC-based analytics is something that the health care payers can
implement today, and start reaping big benefits.
Introducing Episode 360TM – a 360 degree view of every episode of care in your
data, allows you to get a single consolidated view from a variety of systems – claims, laboratory,pharmacy, dental, and vision, to name a few.
It helps you slice and dice, and completely analyze:
The performance of health care providers
High dollar episodes
Top procedures overview, and other similar business focus areas
Episode 360 TM is an end-to-end Business Intelligence (BI) solution comprising:
Dashboards and scorecards that provide vital Key Performance Indicators (KPI) to users – fromoperational decision-making analysts to analytical decision-making executives
Enterprise Reporting capability from a central consolidated data repository
2Greene, Robert, MD, FACP, “Why use episode of care methodology?” PAI Seminar – Understanding Episodes of care, Chicago, June 22, 2007
(www.ismanet.org/pdf/resources/PowerPoint%20Presentations/PAI%20-%203%20Why%20useful%20FINAL.ppt)
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Flexibility DeliveredThe implementation of PPC’s Episode 360 TM solution is vendor agnostic, thus allowing companies to
leverage their current investments in business intelligence and data integration tools.
With our ready-to-go data warehouse models and report templates, your organization will need to invest
minimum effort to integrate our solution with your current environment. The figure below illustrates a high-
level architecture of Episode 360 TM.
Figure 1: Episode 360 TM System
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Benefits Realized
Episode 360 TM allows MCOs to focus on health care costs.
You cannot control what you cannot measure. Using data
to facilitate cost comparisons across delivery systems,
bundling related treatments into logical packages of
EOCs, and providing visibility into pricing data are all
capabilities offered by Episode 360 TM, thus allowing
MCO’s to measure, and ultimately control, costs.
As an end-to-end Business Intelligence solution, Episode
360 TM not only offers significant capabilities out-of-box for
faster time to value, but can also be extended to related
areas to provide a single view of patients or of providers.Below are some examples of the analysis that can be
performed using this BI solution:
Process Area Episode360 Reports Data Sources
Identify your providers Create a 360 degree view of providers bydeduplication of provider information existingin multiple systems
Identify high volume providers and assesstheir business value/costs
CRM Application
Plans System
General Ledger
Improve Operations Track dollars spent on physicians, facilities,and pharmacies
Optimize provider networks
Understand provider quality metrics tosupport ‘Pay for performance’
Provider System
Pharmacy System
Plans System
Claims System
Meet customer needs Analyze cost/benefit ratio of bringing newproducts to market
Plans System
Claims System
Call Center Log
Source: Rajeev Kumar, Adaptive Insurance Data Warehouse
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ConclusionIt is clear that Business Intelligence has a significant role to play as health care organizations try to
understand all of the cost components of various treatments and use this information to develop average
costs for procedures, such as hip replacements and heart surgeries. Industry-standard cost comparisons
that look across providers are not far away.
The logical next step is to provide accessibility to this data to facilitate consumer choice based on pricing
and, looking forward, on quality of care. Medicare is already reporting on common costs for physicians
and hospital procedures, and insurers are beginning to provide cost comparison data to their customers.
As this trend continues, providers will have no choice but to focus on cost analysis themselves,
particularly, if their pricing is outside industry norms.
To remain competitive in the market, Managed Care Organizations must become more agile and employ
efficient ways of looking at organizational data for improving efficiencies, reducing costs, and managing
risks. Towards this end, PPC’s Episode 360 TM can be a very important, and powerful, tool in their hands.
About Project Performance CorporationProject Performance Corporation (PPC), part of the AEA group, is a management consulting firm
integrating world leading expertise in the areas of environment and energy with cutting edge IT and global
management. Our customers include Fortune 500 and top government decision makers.
PPC offers a unique blend of experience combining our understanding of the customer and subject matter
expertise with information technology to devise a meaningful solution that make a difference. Visit us at
www.ppc.com.
PPC offers a wide range of expertise for the health insurance industry. PPC service areas include:
Business Intelligence and Data Warehousing
Master Data Management
Business Process Management
Portal Solutions
Knowledge Management
Enterprise Security
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4 Lisa Loftis, "Transforming Health Care with BI", Subset//BI & performance management, Information Management Magazine,
March 2, 2009