using electronic health information and strategic analytics to enhance value based health solutions,...

1 © 2014 Valence Health. All rights reserved.

Clinical Integration

Using Electronic Health Information and Strategic Analytics to Enhance Value Based Health Solutions, Improve Care Delivery and Advance Care Coordination HFMA Texas Gulf Coast & HIMMS South Central

Texas Chapter Joint Meeting

September 26, 2014



Objectives

1 Understand What’s Fueling “Big Data” Discussions in Healthcare

2 Learn How Texas’ Children’s Health Plan is Using Electronic Health Information and Strategic Analytics

3 Address Your Questions


Clinical Integration ACA is Providing Incentives for Providers and Hospitals to Overcome Distrust and Align for Common Gain

Lack of Shared

Incentives

Lack of Physician

Governance

Fragmented Structure

• Long term contracts offered with no productivity terms or quality incentives

• Physicians were promised a greater say that was never delivered

• Hospitals failed to organize multiple physician groups into a cohesive units

• Lack of communication tools

Pre-ACA Implementation1 Post-ACA Implementation3

Aligned Incentives

Demand for Coordinated

Care

Technology Incentives2

• Bundled payments • Shared savings / risk

arrangements • Must manage care

together • Safe harbor for physicians

and hospitals to operate

• Penalties for poor quality scores for hospitals

• Staying on top of quality scores means improving physician relationships

• Meaningful Use initiatives provide incentives for investment in technology that improves coordination

• Overcome data issues

$

1) Deloitte Center for Health Solutions. “Physician-hospital employment: This time it’s different.” 2013. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Center%20for%20health%20solutions/us_lshc_PhysicianHospitalEmployment_090313.pd

2) Centers for Medicare & Medicaid Services. 2014 Definition of Stage 1 of Meaningful Use. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html 3) PwC Health Research Institute. “From courtship to marriage: A two part series on physician-hospital alignment.” 2011. http://thehill.com/images/stories/blogs/pwc%20trust.pdf

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html








What We Are Seeing in the Market Model ↑↓ Trends

Clinically Integrated Networks

• Major momentum in many/most markets • Drivers different by market “type” • Some cross-system collaborations • Some IPA/Physician lead models, but

mostly hospital / system supported

ACOs and Full Risk Contracts

• Commercial and Medicare ~50/50 • Latest batch of MSSP about to be

released to applicants • Data reporting/sharing often still

problematic • Seeing selected expansion of full-risk

contracts – some provider inspired • Medicaid risk contracts in some states

Provider-Sponsored Plans

• Some marquis growth (Sutter, NSLIJ) and smaller players (CHOMP, Florida Hospital, solutions

• ABCO says 1 in 5 systems to be payors by 2018

Bundled Payments

• Still limited in total application • Still focused around cardio, ortho and

birth episodes/procedures • Illinois Bone and Joint - Leader

PCMH • ~5000 accredited sites

• New growth has slowed • Funding from commercial payors may be

focused elsewhere

41 138

356

606

0

100

200

300

400

500

600

700

Q4 2010 Q4 2011 Q4 2012 Q4 2013

Rapid Growth of ACOs Year Over Year1

Number of ACOs by Referral Region1

1) Leavitt Partners Center for Accountable Care Intelligence, 2014


Clinical Integration Inputs and Outputs that Support Quality and Risk Management

Clinical Measures and Quality

Improvement

Population Analytics for Risk

Stratification

Programmatic Risk Management Portal

Inputs: Multiple Sites and Data Sources

Outputs: Population Management with Decision Support Functionality

• National measures (e.g. HEDIS) • CI measures • Risk measures – and how they are

different

• Population health reporting • Identification of gaps in care and high-risk

patients

• Proficient and proactive performance management

• Physician report cards • Registries and action lists for each patient

(e.g. overdue care)

Physician Offices Practice Management Systems, EHRs

Hospital Data ADT, Billing Data, Demographics

Lab Data Quest, LabCorp, Other

PBM Data

Post-Acute Data Claims Based

Payor Data Eligibility, Paid Medical Claims

360o Clinical Information for

Affiliates

• Virtual medical records support POC risk management

• ED and Hospitalization alerts • Encourages in-network referral


Clinical Integration Attribution of Members to Providers is Critically important for Population Health Management

Attribution assignment can be…

• Assigned by the payor or EMR • Based on number and type of E&M codes • Assigned using ranked specialists • Triggered by Dx or Px • More customized, if client wishes

Attribution is key to creating joint accountability for risk and quality. Configuration can be based on: • Provider type: specialty type, PCP, PCP

subtypes • Single or multiple attribution: including

groups as defined by geography or specialty • By encounter detail: counts, types, and

diagnoses specific • Configurable at the measure level • Any permutation of the above

Member matching capabilities reliably and accurately link unique individuals across EMRs, PMS, labs, Rx data, professional services, hospitals, and other institutions. Algorithms are: • Tuned to enhance specificity and avoid false

negatives • High matching rates with capabilities for manual

clinician directed merging • Incorporate advanced statistical methodologies

including probabilistic matching, Bayesian algorithms, and deterministic logic

Attribution Member Matching



Objectives


2 Understand How Texas’ Children’s Health Plan is Using Electronic Health Information and Strategic Analytics

3 Answer Your Questions



The Center for Children and Women

Texas Children’s

Texas Children’s Hospital

Texas Children’s Pediatrics

Texas Children’s Physician Services

Organization

Texas Children’s Women’s Specialist

Texas Children’s

Health Plan

Texas Children’s

Health Plan—The Center

For Children and Women

TCH Insurance Company,

LTD

Texas Children’s Hospital

Foundation



Background

• Located in the community of Greenspoint and soon Southwest.

• Both areas with large Medicaid populations


Clinical Integration Access



Integration

• Pediatrics • Obstetrics • Behavior Health • Pharmacy • Optometry • Dentistry • Laboratory • Diagnostic Imaging • Speech Therapy



Coordination


Clinical Integration Alignment



HEDIS Metrics


Clinical Integration Valence Reporting Population Management



TCHP Utilization Performance Relative to Peers



• Eligibility • Member Eligibility

o Member months from 2011-2013 o Ages 1-18 o Exclude newborn, pregnant women, TANF adults, and SSI members

• Claims Eligibility o Claims incurred from 2011-2013

• Utilization: defined as rate per 1,000 members per year • Numerator: sum of events • Denominator: sum of member months • Rate: 12,000 * (Numerator / Denominator)

Peer Comparison Methodology for Texas Medicaid Children


Clinical Integration TCHP is the Highest Performing System, Achieving a 61% Reduction in ED Visits Relative to its Peers

Medicaid Pediatric ED visits, by Provider system Rate per 1,000; Payor data; 2011-2013 average

348

435

721

577

894A

C

B

Average 595

D

-61.1%

TCHP

2011-2013 average



TCHP pediatric admission rate is 36% lower that its cohort Medicaid Pediatric Admissions, by Provider System Rate per 1,000; Payor data; 2011-2013 average

19.2

29.9

27.7

18.5

22.4

D

A

B

TCHP

Average 24

C

-35.8%



Objectives


2 Learn How Texas’ Children’s Health Plan is Using Electronic Health Information and Strategic Analytics

3 Answer Your Questions



Contact Us

• Nathan Gunn MD, President of Population Health, Valence Health • [email protected] • Ph: 312-526-7395

• Heidi Schwarzwald MD MPH, Pediatric Director Texas Children’s Health Plan

Center for Children and Women; Vice-Chair for Community Pediatrics, Baylor College of Medicine Department of Pediatrics at Texas Children’s • [email protected] • Ph: 832-828-1538

mailto:[email protected]


