Provider and insurers may not always see eye to eye, but when it comes to analytics, especially around risk-based contracts, both can find common ground in shared population health data.
Insurers provide the broader view from pharmacy benefits and claims paid to outside providers, while hospitals have the deeper information on patient care through electronic medical records and clinical data, according to Ariel Bayewitz, vice president of provider analytics at Anthem.
"Over the past two years, we're seeing a transformation between payer and provider, from what was once transactional and somewhat contentious," Bayewitz said. "It's a total paradigm shift."
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Together, it's a one-two punch in conquering the sometimes elusive savings in value-based care.
Anthem, one of the country's largest insurers, has been on the forefront of leveraging data analytics to get insight into risk.
Providers in shared risk contracts with the insurance giant can realize savings in acting on Anthem's data of specific patients at risk.
Anthem's predictive analytics give providers an opportunity to do interventions, gives them knowledge on outside care visits, such as to a behavioral health specialist, on those at highest risk for being admitted or readmitted, and on gaps in care.
From the data, providers can see a trend in what's driving the cost of care, and make appropriate changes to treat the at-risk patient.
"Providers that are in gain share, especially in risk models, it's in their best interest to improve outcomes," Bayewitz said. "If not, they're not making any money in the program."
For providers not in risk contracts, the data gives a push to lower cost and increase quality, the basis for value-based care.
Increasingly, more providers are taking part in alternative payment models with Anthem, according to Bayewitz.
"When you look at shared savings and risk models for managing total cost of care, there's $30 billion tied to such arrangements in alternative payment models," Bayewitz said.
These payment models include not only HMOs, but preferred provider organizations.
For Anthem and other insurers, the benefit is saving money through managing risk.
"We needed to analyze cost of care on a population basis," Bayewitz said. "We need to project costs of care to model out what costs will be in the future. On an overall basis, we've seen significant reductions in hospital admissions, surgical costs … we've seen improvements in quality measures. There's more opportunity out there."
Benevera Health in New England is a joint venture that combines providers, payers and analytics. It includes insurer Harvard Pilgrim Health Care and New Hampshire providers Dartmouth-Hitchcock Health, Elliot Health System, Frisbie Memorial Hospital and St. Joseph Hospital.
The partners share in the profit and loss of all of Harvard Pilgrim Health Care's insured members in New Hampshire, whether they receive care from providers in or out of the partnership
Benevera launched in October 2015 and started risk deals in 2016, according to CEO Corbin Petro, a former chief operating officer at MassHealth, Massachusetts' Office of Medicaid..
The providers take risk on their own and also share in the risk on Harvard Pilgrim's entire book of business in New Hampshire, Petro said.
"They've very invested in the insurance market in this arrangement," Petro said.
Benevera combines the electronic medical record data and claims data to create a population health entity and patient stratification.
"What we do is help them move along the risk and value continuum," Petro said of the providers. "If their only risk contract is with Harvard Pilgrim and Benevera, they're less likely to change that model (with other payers)."
The data comes from multiple sources and information such as pharmacy reconciliation goes into an algorithm.
The results show a reduction in cost in the 30 to 40 percent range for the patients engaged through population health efforts.
"We hear great results how we're engaging patients," Petro said. "We're able to identify them sooner because of data we have."
Benevera began by hiring social workers and behavioral health specialists.
Interactions with patients could include help in getting fuel assistance or transportation. There's more communicating with patients, and some home visits, according to Petro.
"We found the support in everything else in their lives is important to overall health and to relationships, even if it's not initially of clinical value," she said.
The Medicare ACO population is leveraging Benevera as a resource, identifying and analyzing patients.
"Where it saves them is around is manage risk," Petro said. "It helps them move towards a value-based world."
It's technology that some of the health systems wouldn't have been able to afford on their own.
Bayewitz said that some ACOs have very sophisticated clinical risk models, but still value the information Anthem gives them.
Yet he said, "Some of the best practices I have seen don't have the technology, they're just incredibly engaged. They've transformed their practices around population health. They're saving money with what we have. Even high performing providers show improvement."