As a Standard & Poor's report finds many insurers are missing the mark on their risk-adjustment predictions, a new partnership between population health management consultant Evolent Health and Health Fidelity, which develops technology to steer providers towards value-based care, aims to fill the gap.
"These organizations are trying to understand, what is their risk profile?" said Health Fidelity CEO Steve Whitehurst. "If you make a mistake on the commercial exchange, those penalties can be significant, you've got a lot of competition. You can't transition unless you understand your population, from Medicare to commercial exchange and ACOs."
Health Fidelity works with providers that participate in Medicare Advantage, Health Insurance Exchange and Medicare ACO programs.
Currently, organizations have 70 to 80 percent of clinical data that is unstructured, Whitehurst said.
Due to the challenges around understanding and analyzing unstructured data, healthcare organizations are managing risk in their Medicare and commercial exchanges using just 20 to 30 percent of available clinical information, he said.
"We're focused on integrated systems for national health plans," Whitehurst said. "We come in and have an added value, we're not competing with them, we're complementing their technology. We're calling it risk optimization."
Using a natural language processing platform, Health Fidelity accesses more data than the typical analytics platform within electronic health records, Whitehurst said.
Currently, discrete data fields are getting only 20 to 30 percent of a patient profile.
"We analyze through algorithms and take information we found and push it back into discrete forms," he said. "It allows the provider or health plan to have access that's actionable."
It's computerized point of care with pull-down menus, in which it's easy to add data to the patient record, he said.
"Unstructured data today sits there," he said. "Evolent will get access to the complete picture of risk and client care, enabling (providers) to make better decisions."
Currently, Health Fidelity and Evolent are working with 10 clients to do an upfront risk assessment of the population.
"With our ability to access that population, we're showing the risk is a lot of greater than what they currently have. The risk profile has been greater than the provider of the health plan has thought," Whitehurst said. "There's been a 30 percent or greater lift."
Like Healthcare Finance on Facebook
Evolent Health streamlines the risk adjustment for new and existing provider-sponsored health plans. Based in Arlington, Virginia, Evolent is independently managed and governed, but is backed by UPMC Health Plan, The Advisory Board and TPG Growth.
Goldman Sachs analysts recently rated Evolent Health as an attractive takeover target due to how well its platforms align with the ongoing shift towards population health and value-based payment. Evolent's software helps track clinical data across a provider's patient pool.
"We think the company is uniquely positioned to benefit from the growing shift to fee-for-value, and its 2Q update highlighted strong growth fundamentals among existing clients as well as a robust pipeline of major health systems," the Goldman Sachs authors wrote.