INTEGRATED DATA ANALYTICS AND CARE WORKFLOW OPTIMIZATION

Transcription

1 INTEGRATED DATA ANALYTICS AND CARE WORKFLOW OPTIMIZATION CASE STUDY October

2 AGENDA INTRODUCTIONS Speaker and System 4 Q+A VALUE OF INTEGRATED DATA Why effective ACOs require EHR, Claims, and ancillary data (and how to do it) CLINICALLY ENHANCED RISK Discovering a complete picture of your patients and their risk 2

3 INTRODUCTION SPEAKER MARK WEISMAN, MD, FACP Medical Director of Strategy, Innovation, Analytics, and Informatics Chair of the Strategy and New Business Development Committee Sentara Medical Group Board of Directors. Chair of the Clinical Informatics Committee Previous chairman of the department of medicine for Sentara Norfolk General and Leigh hospitals M.D. George Washington University Medical School Internship & Residency North Shore University Hospital - Cornell University 3

4 INTRODUCTION SENTARA HEALTHCARE 126 yr. not-for-profit history 12 hospitals 5 medical groups, providers, employees Optima Health Plan Urgent Care, Home health and hospice, Rehab and therapy, nursing and assisted living. SENTARA MEDICAL GROUP 181 sites 820+ providers (specialty, primary care, urgent care, hospitalists) in VA, NC 1 million patient visits per year 2,700 employees Annual growth 15-20% over next three years 4

5 VALUE OF INTEGRATED DATA WHY EFFECTIVE ACOS REQUIRE EHR, CLAIMS, AND ANCILLARY DATA (AND HOW TO DO IT) 2 5

6 VALUE OF INTEGRATED DATA HOW EHR DATA CREATES VALUE There are a few ways to create value from EHR data in shared risk programs: ROI TYPE Increase Quality ACTIVITY TO DRIVE VALUE VALUE TO PLAN Improve Quality Scores (Stars, HEDIS) 2-5% Increase Revenues Improve Risk Premiums (HCC) Cost of Care Improved Member Identification for DM EHR DATA RETRIEVAL METHOD DEPTH OF DATA $ pmpy retrospective $1200-$2800 pmpy prospective Full Backend Access $4.15 pmpy Auditable ex. NCQA guideline 39 HIE/CCD/HL7 6

7 INTRODUCTION FEE FOR SERVICE VS. MEDICARE ADVANTAGE Fee For Service CMS $100 $1000 $100 $$ $1200 Health $$ plan Medicare Advantage HCC to CMS HCC Diagnosis codes + $100 $100 $$ $1000 If yes, health plan pays doctor ½ of every % below 87.5% $1200 $$ Health plan CMS pays health plan $$ per member per month, based on HCC codes submitted Health plan: Is medical expense 87.5% or less of CMS payment? Is quality and experience 4 or 5 STAR? 7

8 VALUE OF INTEGRATED DATA THE OPPORTUNITY DEEP EHR DATA BRINGS CLAIMS DATA ONLY John Doe is a 76 year old male with a primary care visit on 5/4/2015 with a diagnosis of obesity. The visit cost $150. INTEGRATED DEEP EHR + CLAIMS DATA John Doe is a 76 year old male who speaks Spanish primarily and is a veteran who was homeless. He smokes 1 pack/day and has a BMI of 33. His BP is 140/80 and has been increasing in the past few visits. He takes Aspirin from CVS. John arrived 10 minutes late for his Primary Care visit on 5/4/2015. In that visit, a Depression Screen was administered (at risk) as well as a Fall Risk Screen. A referral to a nutritional counselor was made, but John never followed up. Additionally, a follow-up was scheduled for a BP check, but John never showed. 2 phone calls were made to the number on file, with no answer. Billed Procedures Billed Diagnoses Paid Claims Encounter History Unbilled Problems/Conditions Expanded Demographics Lab Results Vitals OTC Medications Social Indicators Phone Encounters Point-of-Care Observations Appointments Unstructured Notes Patient Engagement Levels 8

9 VALUE OF INTEGRATED DATA TECHNOLOGY BACKBONE IDX EPM EPIC EHR OPTIMA CLAIMS HUMANA CLAIMS DATA CONNECT UNIFIED DATA WAREHOUSE HCC AND MEASURE CALCULATIONS WEB PORTAL (INCL HCC NAVIGATOR) SMG has contracted with Arcadia Healthcare Solutions to implement a Risk Management platform for Sentara to support complete and accurate coding for risk adjusted populations. The Arcadia HCC Navigator application consumes claims and clinical data from the following systems: Epic EHR IDX Enterprise Task Management (EPM). Data needed from IDX is restricted to charge, appointment, patient provider, location of service and diagnosis codes on charge. Optima Claims Humana Claims 9

10 CLINICALLY ENHANCED RISK DISCOVERING A COMPLETE PICTURE OF YOUR PATIENTS AND THEIR RISK 4 10

11 CLINICALLY ENHANCED RISK CURRENT RISK MANAGEMENT PROCESSES Current, mostly manual, processes are time consuming and only allow for auditing of a small number of charts per month Ongoing Audits 10 charts a month to audit using Epic and online tools on SharePoint (most Clinical Coding Coaches have 1or 2 sites) Auditing is done remotely and payment is based on # charts rather than on time goal min a chart. Monthly meeting All Clinical Coding Coaches meet monthly Thursday 4-5 via Web Ex Feedback about program, tools, process, and HCC codes frequently missed. Receive coaching tool/tip sheets to use in peer to peer coaching sessions with providers. One quarterly meeting at each assigned practice site(s) Practice meeting is for minutes with assigned provider practice 1-2 sites per Clinical Coding Coaches Content: explain the why of HCC, and global tips on commonly missed HCC codes, documentation improvements, and share audit findings as a group for group learning. (Agenda and resources provided) 11

12 CLINICALLY ENHANCED RISK UPSIDE IN TODAY S PROCESS Today s process for documenting and caring for patients with risk leaves a lot to be desired, both in terms of the care the patient is receiving, and the financial compensation that the health system or plan is receiving from CMS. DOCUMENTATION COLLECTION Documentation on the risk of the patient is collected by the health plan, and CMS through claims diagnosis submitted by the providers, and augmented where possible with full chart pulls and reviews by certified coders, or nurses working for the health plan. 1-2% $ pmpy is left on the table due to the ineffectiveness of today s processes. INTERVENTION Health Plans attempt to intervene and support providers by sending long list of patients that the plan believes need to be seen or where documentation needs to be improved. Up to $2,800 pmpy is left on the 10-28% table due to the inability to help providers at the point of care. 12

13 CLINICALLY ENHANCED RISK WHERE THE PROCESS BREAKS DOWN 13

14 CLINICALLY ENHANCED RISK PATIENT RISK REGISTRIES WHAT IT CAN DO Unified patient registry presents patient complexity across 85 condition categories. Tr a c k p a t i e n t r i s k a n d f i n d documentation gaps leading to underrepresented acuity. High Cost and High Risk prioritization Dozens of decision support rules and alerts highlight quality gaps Integration with scheduling data for highly relevant pre-visit planning reports. Customize and share your lists with other members of the care team. 14

15 CLINICALLY ENHANCED RISK COST AND UTILIZATION MANAGEMENT WHAT IT CAN DO Visualize procedures, diagnoses, and DRGs. Analyze performance on multiple contracts C o s t P M P M, E v e n t s / , R e a d m i s s i o n s a n d Av o i d a b l e Emergency Department Usage Unique risk-adjusted metrics with EHR data Over a dozen core metrics and 20+ filters and comparison dimensions Leakage analytics to steer referrals in-network G o o g l e M a p s i n t e g r a t i o n f o r advanced hotspotting and community engagement 15

16 CLINICALLY ENHANCED RISK EXAMPLE RESULTS SUMMARY In this particular example, which had a heavily risk pruned patient population, Arcadia found over a 12% improvement in premiums. $7.28 pmpm attributed to documentation gaps with 98.5% accuracy and another $77.65 pmpm attributed to possible care interventions. Premium Adjustment from Documentation Gaps $ pmpm + $7.28 pmpm Total Premium Opportunity + Finalized Premium from RAPS & Demographic $77.65 pmpm = $ pmpm 12.3% Premium Adjustment from Interventions 16

17 QUESTIONS? 17