Health Care and Cognitive Analytics. Melissa Robinson/Jennifer Pratt NC TIDE May 26 th, 2017

Transcription

1 Health Care and Cognitive Analytics Melissa Robinson/Jennifer Pratt NC TIDE May 26 th, 2017

2 Watson Health Government Mission Watson Health aspires to help governments improve health and human services value and have a meaningful impact on people s lives through the power of cognitive insights. 2 Watson Health IBM Corporation 2016

3 NCAnalytics: A Multi-Payer Data Warehouse Solution Department of Justice Medicaid Investigations Division pursuit of fraud, waste & abuse Division of Mental Health Mental Health Developmental Disabilities Substance Abuse Services Division of Medical Assistance Medicaid Health Choice Division of Public Health Sickle Cell Early Hearing Detection and Intervention Infant Toddler Program Office of Rural Health 3

4 GBS Program Integrity Presence Current GBS Program Integrity Projects GBS consultants are embedded within PI on site providing analytic services and support. Consulting Services Process consulting, Policy reviews, Reporting, Sampling and extrapolation for audit strategies Predictive Analytcs Use all available analytic capabilities, including FAMS, and Identity Insight to identify providers for Prepayment Review Program or Post Payment Audit These capabilites are available to both program integrity and all MCOs. Actual MCO claims are directly received, rather than encounters, and are loaded into the FAMS datamart on a monthly basis. MCO users have access to FAMS. Network Integrity Utilize Identity Insight to perform entity analytics using internal and external 3 rd party data sources to: 1) screen high risk incoming provider applications 2) Analyze beneficiaries 3) Analyze providers 4) Perform network analytics 4

5 Solutions & Offerings 5 Watson Health IBM Corporation 2016

6 Addressing Mental Health Need for services Use of services Trends Benchmarks Quality measures 1. Assess Current Situation 2. Identify and Engage At-Risk Populations Demographics Mental Health history Rx History Co-occurring mental illness Chronic pain patients Evidence-based Benefits Standards of Care Strong Network Plan Quality Measures Care Coordination Adolescent/Youth Services Strategies to Address Abuse Program Integrity Safeguards 4. Transform Delivery System per CMS 3. Assess & Improve Programs Clinical & Prescribing guidelines Pharmacy benefit policies Access to Medication Assisted Treatment Health Homes Access to Care & Treatment 6 6

7 Offerings and Capabilities Support Individuals and Families Individual & Family Engagement Delivering benefits and leveraging a community of resources to support individuals and families. Social Program Management End-to-End workflow targeted at managing health and social program administration, including eligibility, benefit management, and family support programs Care Management Manage high-cost and high-need individuals, and demonstrate a reduction in health and social care expenditures through integrated care delivery models Risk Identification Identifying at-risk individuals, monitoring the health of the programs and modeling opportunities for intervention. Advanced Analytics Understanding those population segments absorbing the greatest amount of clinical and social costs and predicting opportunities for intervention HHS Consulting Policy and Program Support to advance agency goals, including: Quality and Delivery, Behavioral Health, Aging and Disability Services, Program Integrity and Medicaid Program Integrity Provides policy makers and investigators insights from an ever-expanding volume of content on how to address fraud, waste, abuse, and error Data Warehousing Data Warehousing Aggregating claims and social data into a single data warehouse for a single view of health and social expenditures Health Data Claims data, clinical data and other relevant sources Social Data Social determinants, eligibility data, care management outcomes 7

8 Knowledge and evidence base to improve access to effective prevention and treatment Substance Use Disorder Consulting Needs Assessment Evaluate the level of need for preventive, treatment and recovery services in state and local communities; identify gaps and improvement opportunities Case Management Identify evidence-based practices, e.g., physician education on appropriate use of opioid medications, and ways to increase patient access to evidence-based treatment protocols. Quality & Performance Metrics Measure access and quality of care (e.g., treatment posthospitalization), target performance improvement initiatives, and assess impact of recently implemented programs. Transformed Delivery System Support states in designing a transformed SUD system that covers the full continuum of care and applies industry standards for defining medical necessity 8

9 Care Management: Care plans that deliver knowledge, behavioral change, and value Care Management Intake and Assessment Quickly identify services, screenings, and products which may meet Citizens needs by assisting with a range of social programs for individuals and their families. Case Management Can help customers identify their clients in need of care, assess needs, establish appropriate care plans, manage the care, and monitor results and outcomes.. Extended Care Team Collaborative Manage high-cost, high-need clients and demonstrate reduction in health and social care expenditures through coordinated care models and the delivery of benefits and services across boundaries. Investigation and Appeals Help capture evidence relevant to social assistance programs and from a single point of vie,, help enable caseworkers to manage aspects of evidence management, including verification. 9

10 Engagement Dialog & Physician Engagement just give us the data transparency on the methods / metrics more predictive capabilities keep it simple how am I doing? how do I compare? make it actionable tell the story Tell me something I don t know about my patient 10

11 Advantage Suite Overview Beneficiary Management Provider Management Program Management Operations Management Program Integrity Management Managed Care Management Care Management Dashboard measures of program performance Advanced clinical analysis and external benchmarks Fully integrates claims and encounter data Provider profiling that uses widely accepted methods for case-mix adjustment Recipient profiling, demographics, costsharing, & population trend analysis Quality assurance and quality improvement Disease management E&M including predictive modeling CMS-certified SURS reporting, as well as fraud and abuse detection 11

12 Advantage Suite Medical Episode Grouper: Medical Episode Grouper Truven s proprietary episode grouping methodology and software which creates a summary record related to a given occurrence of a condition for a particular patient Based on the Medstat Disease Staging classification system Developed by Truven (then Medstat) and Jefferson Medical College in 1983 under contract to NCHSR (now AHRQ) Classification system based on disease severity without regard to treatment Groups together inpatient, outpatient, and drug claims using: Disease Staging patient classification system Clean Periods derived clinically and empirically 12

13 What audience was Advantage Suite Medical Episode Grouper (MEG) created for and the value proposition? MEG was originally created for hospitals and payers. The intended audience for MEG is based on disease staging from peer reviewed disease classification and severity stratification scheme. It is built to allow clinical relevance to appropriateness of care measurements. MEG incorporates the fifth edition Disease Staging patient classification system with 555 disease categories - enabling a sophisticated understanding of conditions, disease progression, and care choices. To ensure alignment with the latest advances in medicine, Truven Health maintains a distinguished panel of experts including over 50 physician specialists, and every disease category within MEG is reviewed by at least three physicians. Truven invests in this effort continually so clients do not have to. With MEG, you can focus on critical clinical and medical program needs using the MEG application capabilities, such as provider profiling, disease management, quality improvement, and cost and use analysis. All of these capabilities can assist in the management and oversight of your LME MCO program. 13

14 Advantage Suite & Interactive Reporting 14

15 Evaluate What s Driving Expenses and Utilization One of Many Financial Management Reports 15

16 Determine If Your Members Are Receiving Appropriate Care One of Many Clinical Management Reports 16

17 Drill Down in the Cost by Month Interactive Report 3 Use Page Controls to View More Top Conditions for the Month Track Trends and Fluctuations in Costs Over 12 Months 17

18 Interactive Reporting Benefits 18

19 Proven Results Center for Financing Reform and Innovation Assistant Secretary for Planning and Evaluation CMS Behavioral Health Clinic Demonstration Improving access and treatment Technical assistance to states including Pennsylvania on Substance Use Disorder (SUD) treatment through targeted learning collaborative covering data analytics, integration of primary care and SUD services, benefit design, payment reform, performance metrics, and managed care contracting. Expanding knowledge base Reviewed Medicaid financing of medications to treat alcohol and opioid use disorders, estimated treatment costs for inpatient hospitalizations for opioid abuse and misuse, and examined treatment patterns before and after an opioidrelated hospitalization. Identifying best practices Conducting research to identify factors that health plans use to achieve relatively high rates of initiation and engagement in SUD treatment, including models of care as well as market factors that affect performance, to help guide improvements in care delivery. Prospective Payment System Assisted CMS in supporting states and other stakeholders as they applied for competitive grants to establish and implement a Medicaid Prospective Payment System (PPS) for reimbursing certified Community Behavioral Health Clinics(CCBHCs). 19

20 Supporting the Third Care Pathway Rory O Connor NC TIDE May 26 th, 2017

21 Integrated Care is a person-centric service delivery model where health and social care are provided in an integrated and coordinated way to improve outcomes. 21 Watson Health IBM Corporation 2016

22 Why we need Integrated Care People suffering from chronic/complex diseases also frequently experience important social needs This situation is even more important in a world where dependency and disability is on the rise due to (among other things): ageing mental health visibility gains of people with disabilities occupational risks shifting from traditional to non-traditional family composition 22

23 Integrated Care - The Third Care Pathway Integrated Care 1 2 Coordinated Articulated Linked Isolated Coordinated Articulated Linked Isolated Health Care Sector 3 Social Care Sector Integrated Care can be achieved via one of three paths: 1. evolving from health care coordination 2. evolving from social care coordination, or 3. starting right from the beginning with an integrated care approach 23

24 Health Care Coordination is Complex Fit and active 69 year old Prior history of breast cancer Recent heart issues Suffered increasing stomach discomfort over the previous year Lack of appetite, weight loss, sleep issues My Mum The Patient 24

25 Evolving to Integrated Care from health care coordination The most common model for people to follow Typically led by a care coordinator with health care background (registered nurses, etc.) Tends to focus more on coordination between healthcare professionals and identifying opportunities to bring in social/community-based services 25

26 Social Care Coordination is Complex My Wife The Social Worker 26

27 Evolving to Integrated Care from social care coordination Instituted by government organizations who are recognizing the health care needs of the citizens they serve through social programs and services Typically led by a care coordinator from a social work background Focuses more on behavioral issues and relationships; healthcare knowledge is unreliable 27

28 Starting with an integrated care approach Very often driven by collaborative policies, but not necessarily integrated organizations Who will coordinate care in a model like this? Where do we find professionals with requisite qualifications? Who pays for them? Often ends up being either the individual themselves, or their caregiver, who does most of the coordination Drives the need for new kinds of systems which can support them 28

29 Supporting the Third Care Pathway with Technology 29 Watson Health IBM Corporation 2016

30 System characteristics Traditional, rules-based software systems aren t well placed to serve people with such complex, individualized needs Instead, need to try and replicate some of the characteristics of a trained care coordinator: interact with individuals in an unstructured format guide people as to what to do next without being prescriptive know when the right time to involve people with more expertise is help people make decisions through reasoned recommendations be flexible enough to adapt to changing circumstances and knowledge 30

31 How Are Cognitive Systems Different? Understand Understand imagery, language, and other unstructured data similar to what humans do. Reason Can reason, grasp underlying concepts, form hypotheses, and infer and extract ideas. Learn With each data point, interaction, and outcome, develop and sharpen expertise, so they never stop learning. 31

32 Interacting with people Interactive Q&A Multi-Modal Portals 32

33 Understanding People Natural Language Processing Personality Insights 33

34 Notifying Care Team Members Intelligent Alerts prompting relevant care team members 34

35 Supporting People s Care Decisions Advanced analytics to help narrow-down options 35

36 Adapting to new knowledge Evolving, knowledge-based recommendations 36

37 Conclusion Traditional models of care aren t working for complex people with a mix of health and social needs Starting with an Integrated Care approach (the 3 rd Care Pathway) requires new systems which can support patients and their caregivers, and help link them with their care team as needed Harnessing the power of Cognitive computing will be key to building systems which can understand and interact with individuals following this path We re on a journey to try and make that a reality, and we d love to talk to you if you want to be a part of it roconno@us.ibm.com 37

38 Q&A 38 Watson Health IBM Corporation 2016