Observing, learning, and acting upon combined clinical, administrative and financial data promotes strong, sustained payer/provider collaboration

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Rosalind Richards
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1 WHITE PAPER Observing, learning, and acting upon combined clinical, administrative and financial data promotes strong, sustained payer/provider collaboration Timely access to actionable clinical and business information at the edge of the enterprise anchors accountable patient care Table of Contents Executive Summary... 2 Introduction... 2 Value of combined data... 2 A new approach: Edifecs collaboration products Conclusion (continued)

2 Executive Summary Healthcare and payment reform profoundly affect the relationship between payers and providers. Increasingly, payer/provider collaboration aims to lower costs while enhancing quality. Yet success may be hindered not only by performance but by lack of timely, focused access to actionable data for patient and member care. Edifecs proposes a new solution: leveraging infrastructure already used by payers and providers to benefit from data identified at the edge of the enterprise. Now both historical and incoming clinical, administrative and financial data can be observed, validated and linked to create comprehensive member- or patient-centric records. These transparent records not only afford stakeholders a common context but empower them to learn from the wealth of combined information in a more timely fashion. This enables payers and providers to take immediate action toward improving quality and mitigating risk by changing behavior, reducing costs and minimizing care variation: the ultimate goal of payer/provider collaboration. Introduction Healthcare and payment reform drives an increasing need for successful payer/ provider collaboration. Such collaboration ranges from profound understanding and shared philosophies about healthcare to the relative simplicity of financial arrangements. These can be as straightforward as fee-for-service improvements or as comprehensive as shared savings and risk agreements. No matter the method, the goal remains the same: lowering costs of providing care while simultaneously improving (and documenting) its quality. Yet operational challenges abound. Efforts to lower costs and mitigate clinical and financial risk need near real-time, actionable data. With today s fragmented healthcare system and limited care resources, less than effective information exchange between disparate data sources makes timely intervention difficult. In Edifecs opinion, combining incoming and historical clinical, administrative and financial data at the edge of the enterprise on any member or patient is foundational to successful collaboration. Transparent data allow for a common context and generates opportunities for more timely and focused clinical intervention and business actions, relieving constrained resources. In fact, Edifecs believes shared access to such a combined data set one which draws information from existing payer and provider systems uniquely positions both parties to mitigate clinical and financial risks and reduce network leakage. Edifecs asserts that this well-timed information underscores critical goals. It supports effective decision-making toward lowering costs and variability of care, without diminishing care quality. Robust datasharing and analytics are vital for successful care coordination. Yet a fundamental challenge remains: getting value from discrete clinical and financial data is difficult. Discussion Value of combined data Studies are plentiful, and clear. When payers and providers work together to enhance the care experience, improve patient health and decrease costs, outcomes are five to ten times better than typical primary care results. Patients experience fewer hospital days, admissions and readmissions than their unmanaged cohorts. Member costs fall, but clinical quality metrics rank consistently high. Transparency and consensus, particularly around data sources and performance measurement, are vital for reform. These qualities develop trust between payer and 2

3 provider and improve efforts to chart greater quality at reduced cost. Robust datasharing and analytics are vital for successful care management and coordination. Yet a fundamental challenge remains: getting value from discrete clinical and financial data is difficult. Payers and providers disparate data systems inhibit the ability to correlate clinical data and coordinate care. Member and patient records are fragmented among stakeholders. Lags in claim submission and processing impede the capacity to act on timely information for early intervention, despite their traditional use for exactly this aim by many payers. Edifecs collaboration products enable payers to identify opportunities for medical review well before the claim arrives. These same products empower providers to collaborate with a payer to align intervention efforts. Many would agree shared, automated access to combined clinical, administrative and financial data benefits all stakeholders. Sourced from payers core systems, effective collaboration products could leverage existing valuable administrative and financial data such as members health records and claims history. This information could help providers decision-making by increasing the fidelity of patient health records, allowing insight into the healthcare services patients have already received from other providers and thus potentially reduce care redundancy and fraud. These same collaboration products could take advantage of the rich clinical and administrative information currently housed in providers information systems. Patients histories and admissions, discharge and transfer data could help payers create stronger member health records, in that way fostering greater continuity of care despite limited medical management resources. Access to existing data fulfills only part of the true value required for successful payer/provider collaboration. Early, or even timely, intervention requires access to new, incoming data in real-time data presented at the edge of the enterprise. It s challenging enough to achieve care quality by combining incoming and existing clinical, administrative and financial data on a patient or member. It s exponentially more difficult when these data are aggregated across a population. In addition, these transparent, combined data could support the shared reporting and analysis-of-care metrics required for value-based reimbursement programs and quality initiatives. For example, if a program s performance requirements include both cost and quality measures, providers need access to relevant and timely clinical and claims information. Otherwise they ll be unable track or analyze the costs, utilization and risk profile of their patients. At the same time, payers need to access these same data to not only identify and manage risk, but appropriately assist providers in managing plan membership and network leakage. Edifecs collaboration products: observe, learn and act on combined data to change behavior and positively impact costs and care variation Combining real-time and historical clinical and financial data from disparate systems is problematic. Unlike other alternatives, Edifecs proposes a new solution specifically designed to address these challenges at the edge of the enterprise: leveraging a payer s use of its existing trading and connectivity infrastructure to receive financial transactions from providers. This infrastructure already effectively transports information from providers to payers, and transmits data back again. Yet these connectivity channels can also be applied to receive additional clinical and administrative data from providers in a considerably more timely fashion to generate a common context of care. The Edifecs technology (see figure 1) is designed to receive financial transactions from providers and can create significant additional value for all involved 3

4 stakeholders. This technology streamlines exchange of a payer s administrative and financial data with that of the provider, and a provider s clinical and administrative data with that of a payer. In addition, Edifecs collaboration products: Observe, validate and link incoming clinical, administrative and financial data with historical information at the edge of the enterprise to create comprehensive patient- and member-centric records Learn from these data to identify key clinical and financial risk markers Distribute these real-time insights to key stakeholders to allow for early intervention, which also strengthens payer/provider collaboration and delivers greater value and quality of care Combine data across multiple axes at the macro level and generate profiles of target populations for greater value in care Eliminate the need to maintain dual administrative and clinical infrastructure for additional collaboration initiatives Providers Payers HIEs Disparate clinical, administrative and financial data Edifecs Collaboration Products Observe, validate and link incoming and historical data Generate memberand patient-centric records Actionable information for clinical and business decision-making Primary care physicians for direct patient care Specialists for clinical diagnostics and support Payers case workers for intervention and disease management ACOs Shared, transparent context of care On-site or cloudbased infrastructure ACO governance team for quality and performance metrics Figure 1 - Edifecs collaboration products designed to observe, learn and act on combined data to change behavior around the costs and variability of care Unlike a data warehouse, new Edifecs collaboration products provide significant benefits with this edge-of-the-enterprise technology. They have the capability to learn from these member- and patient-centric records and identify key, actionable clinical and financial risk markers in a more timely fashion. Broadly speaking, Edifecs customers can apply this actionable information with many clear advantages. In addition to strategic business needs, these include clinical applications in the context of member or patient care and allow already-constrained care resources to focus on those patients or populations most in need of intervention. Edifecs collaboration products make possible: Proactive, automated insights on key risk markers and gaps in care, enabling payers and providers to target intervention early and impact both costs and quality metrics Secure messaging on patient needs, which seamlessly integrates into existing health records and care management systems to further strengthen collaboration efforts Reduction of risks and costs of readmissions by combining clinical and financial discharge records for more robust health records as well as an advantageous continuum of care Improvement in costs of care and clinician productivity through timely insights reducing redundancy and better coordinating care through insight into provider health records Costs and workflow efficiencies associated with prior authorization requirements and letters of medical necessity; these allow faster approvals from payers, increased reimbursement predictability and greater accuracy in patient collections through reduction in bad debts Reductions in network leakage by streamlining communication of appropriate in-network referral opportunities to providers and patients alike 4

5 Edifecs collaboration products give payers the ability to identify opportunities for medical review well before the claim arrives from the provider. In addition, the products empower providers to collaborate with a payer to align timely, targeted intervention efforts. And while such intervention enables payers to decrease the costs and care variation, it also allows providers to enhance their quality of care and performance metrics for value- or qualitybased programs. See figures 2a and 2b for a detailed example. Let s look at the power of Edifecs collaboration products through a practical illustration. These deeper clinical insights for collaborative care indicate the breadth of payer/provider value from combining clinical, administrative and financial data at the edge of the enterprise: A male, 52, with a history of smoking and diabetes presents in the Emergency Room with chest pain, heartburn, and shortness of breath. Edifecs collaboration products observe this incoming ADT event and link it to his existing patient or member health record (figure 2a) Hospital ED Physician Hospital Inpatient Unit Payer Male, 52, history of smoking and diabetes. Presents in ED with chest pain, heartburn, shortness of breath. ED Lab Cardiologist on call Edifecs Collaboration Products ED Arrival HL7 ADT Lab Order HL7 ORM Lab Result HL7 ORU Professional Claim 837 P EKG Order HL7 ORM Professional Claim 837 P EKG Result HL7 ORU Admission, Discharge HL7 ADT, CCD C48 Institutional Claim 837 I Clinical or Discharge Summary CCD C32, CCD C48 Figure 2a Subsequent lab work performed during the encounter indicates elevated cholesterol levels while the care team also notes high blood pressure. The lab results and results from the tests ordered by the consulting cardiologist are observed by Edifecs products in real-time Learning from this information, Edifecs products are able to generate a real-time alert to the patient s care team, including the payer, proactively indicating the patient is at risk for coronary artery disease Male, 52, history of smoking and diabetes. Presents in ED with chest pain, heartburn, shortness of breath. Hospital Patient Discharged PCP Patient follow-up appointment setup Patient referred to nutrition and smoking cessation programs Payer Case Management Teams PCP receives notification with patient condition Edifecs Collaboration Products Longitudinal member- or patient-centric record Insight to PCP about patient admit and condition Notify PCP of care plans Notification with in-network nutrition and smoking cessation programs Insight to payer on program referrals Notify payer of care plans Patient summary with care instructions Insight with care plan to manage diabetes, nutrition, and smoking PCP reports quality of care as performance measure Figure 2b 5

6 Independent of these alerts, the consulting cardiologist indicates concerns of potential coronary artery disease and recommends the patient be admitted for further observation. Traditionally these results and diagnoses would be recorded in the disparate laboratory and hospital information systems and the information would be distributed when convenient to the patient s immediate care team Yet with Edifecs collaboration products also observing these data in real-time, linking them with existing historical information in the patient or member record, and then communicating their significance to both the patient s care team and the payer s member record, a wider array of stakeholders are able to take more timely action. Through use of Edifecs collaboration products, both the payer and care team have immediate insight into the patient s recent diagnosis and past history, enabling them to collaborate on the best means of intervention and care potentially reducing clinical and financial risks and enhancing the quality of care For example, the payer may choose to proactively notify the patient s primary care physician of innetwork nutrition and smoking cessation programs which can benefit the patient at a lower out-of-pocket cost while mitigating the risk of network leakage. The payer can now communicate this notification considerably earlier than if using traditional claims-based analysis While this is recorded in the payer s member record, the primary care physician can also proactively contact the patient to schedule a follow-up appointment to discuss treatment options and, when appropriate, communicate the outcome of these conversations back to the payer strengthening their quality-of-care metrics as a value-based performance measure in doing so Ultimately, Edifecs collaboration products can empower more coordinated care appropriately and contribute to improved health outcomes while potentially reducing the risk of future adverse events. And with coronary heart disease, the most common type of heart disease, costing the United States $108.9 billion each year, such efforts to support a payer or provider s total population of such patients could have a significant impact Fundamentally, Edifecs believes these collaboration products can tactically generate the common context required to empower payers and providers to improve targeted member or patient outcomes. At the same time, these products allow for the transparent data required to strategically support aligned and focused attempts to change behavior toward reducing costs and care variation; such quality-based efforts remain the ultimate goal of successful payer/provider collaboration. See the examples in figure 3. Reduce risks of readmission Based on observing an incoming ADT feed from a hospital, Edifecs collaboration products can automatically notify a primary care physician and a payer s case management team when patient is discharged from a hospital Given learnings noted in the historical patient- or member-centric record, this event can compel the primary care physician to collaborate with the payer s case manager to schedule a timely follow-up appointment to further continuity of care reducing the risk of readmission and helping the care teams focus on patients most in need Edifecs products not only indicate which patients fail to make these appointments, but tellingly measure which physicians most effectively perform post-discharge follow-up and demonstrate accountable care Focus care management resources Edifecs collaboration products can observe incoming clinical, administrative and financial data at the edge of the enterprise to identify individual patients within a target population in need of focused disease management For example, data estimate the diabetes-related For example, data estimate the diabetes-related hospitalization incidence rate in the United States is approximately 0.23%. Adverse clinical outcomes and patient experience aside, the average cost of such hospitalization is almost $11,000 per patient. Edifecs collaboration products can proactively identify patients with diabetes from a combination of a primary care physician or specialist s EHR and a payer s claims data These products can even identify patients with clinical risk markers indicating the potential to develop diabetes based on incoming lab results. With both sets of data being generated well ahead of a payer s traditional claims-based approach of disease management and intervention, payers can then guide these patients to in-network providers This not only allows for proactive payer- or provider-based care management plans, but seeks to contain unnecessary medical costs successfully aligning incentives toward impacting the costs and variability of their care Figure 3 Simple insights, big gains from transparent, combined clinical, administrative and financial data 6

7 Conclusion No matter how payer/provider collaboration is defined, timely access to actionable data underscores value- and quality-based care. In delivering the information required for success, Edifecs proposes making use of a payer s trading and connectivity infrastructure to receive financial transactions from providers at the edge of the enterprise. In addition, the Edifecs technology that executes this function observes, validates and links incoming clinical, administrative and financial data with historical information to create member- and patientcentric records. The combination of these data empowers both payers and providers to address clinical and financial risks. They gain the timely, valuable and actionable information required to focus individual patient and member care, reduce network leakage and enhance broad population health. Ultimately these data support efforts to change behavior toward reducing costs and variability of care the ultimate quality goals of successful payer/provider collaboration. Legacy of success Edifecs products have supported collaboration between payer and provider for over a decade; examples include tactical solutions such as the collaborative testing suite for ICD-10 migration. Other financial management products develop and analyze shared savings and risk programs. Over 250 healthcare organizations around the United States are Edifecs customers. They include the majority of Blue Plans and over 100 leading provider organizations across 23 states. Most of the state Medicaid agencies have selected Edifecs products, and some of the largest commercial health plans in the country. Altogether these customers serve more than one-third of the U.S. population. i AHIP Institute Presentations by Patrick Courneya, HealthPartners health plan medical director, and Marc Keshishian, senior vice president and chief medical officer for Blue Cross Blue Shield of Michigan s Blue Care Network ii Claffey TF, Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan. Health Aff (Millwood) Sep;31(9): iii Burghard, Fundamentals That Will Drive Successful Analytic Strategies for Accountable Care. IDC Community Insights. idcinsights-community.com retrieved September, 2013 iv Alliance for Health Reform. Pioneer ACOs: Lessons Learned from Participants and Dropouts. Retrieved October, 2013 v Data obtained from the CDC. This total includes the cost of health care services, medications, and lost productivity vi CDC data indicate 688,000 hospital discharges with diabetes as first-listed diagnosis in the United States. Assuming the US population is 305,000,000, this gives a diabetes-related hospitalization incidence rate of approximately 0.23%. vii Data obtained from the AHRQ. An industry leader since 1996, Edifecs provides healthcare software solutions that improve operational performance by streamlining the exchange of information among health plans, hospitals, and other healthcare organizations, while enabling compliance with current mandates such as HIPAA, Operating Rules and ICD-10. Today, more than 250 healthcare customers use Edifecs technology to unify transactions from any information channel source and input mechanism, while automating manual business processes such as enrollment, claims and payments management. Edifecs is currently recognized as one of the 100 Fastest Growing Private Companies in the state of Washington, 100 Best Places to Work in the state of Washington, an Inc fastest-growing private company and one of the 500 Fastest Growing Companies in North America by Deloitte. Edifecs is headquartered in Bellevue, WA. For more information, please visit Edifecs Corporation. All rights Reserved. May, 2013

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