In January, the Department of Health and Human Services set a goal for 50 percent of all Medicare provider payments to be the result of value-based compensation models by 2018.
One of the main challenges facing organizations is combining the sheer amount of data available from disparate locations. Once data are unified and analyzed, organizations can perform proactive outreach of health plan members or plan providers, administer or participate in pay-for-performance programs and improve overall quality of care to maximize revenue.
Organizations can efficiently aggregate existing data and capture additional information needed to perform targeted and effective outreach. When better reporting processes are established, organizations can also track the outcomes of their outreach to inform future efforts. The tools used to support this preventive care program can help both providers and payers successfully navigate the transition to value-based payment models advocated by HHS.
Currently, organizations may be studying utilization and other financial data, but their analyses are incomplete due to inaccessible information spread throughout the organization. Faced with just their own internal data, payers and large provider organizations may be overwhelmed with the task of consolidating and normalizing this information. The next step of creating the types of actionable reporting for effective outreach or educating provider groups about care gaps is not truly feasible until organizations have a grasp on how much information is available and how to align the data.
During the data consolidation process, payer organizations may discover care gaps for potential high-risk member populations. Unfortunately, these gaps may be inaccurate because the most recent clinical data from the members' primary care or specialist physicians are dated due to the timing of data file extracts.
Timely clinical data is essential for performing targeted outreach, especially for high-risk populations.
Reviewers and auditors can ensure care and risk gap reporting accuracy by confirming existing diagnosis data from health plan or provider documentation. Organizations should also have real-time transparency into the chart retrieval and review progress and be able to view operational data at each stage of the project, including provider participation, clinical and quality reviews and revenue impact
Outreach can be conducted on multiple levels, too. For preventive care, analysis can determine members who have not visited a physician's office as recommended or not refilled prescriptions for chronic conditions. New health plan members also require outreach so the payer can build a member disease category profile to improve risk score accuracy and CMS quality scores.
After the outreach program is complete, the data analytics platform and supporting chart retrieval and review services should track the activity and outcomes of the relevant member populations. The results will inform future outreach initiatives, further strengthening the accuracy of the platform's predictive analysis and effectiveness of the interventions, as well as improving the health plan's revenue cycle management.
Payers can support providers by unifying disparate data sources, obtaining more robust and timely clinical data from providers through chart retrievals and supporting targeted member outreach. Payers can also help increase their own CMS HEDIS, Stars or other quality ratings.
Jimmy Liu is vice president, risk analytics services at Altegra Health.