by Lynda Rowe
July 24, 2017
I am the first to admit the value of claims for analytics and reporting. Many years ago when I managed the analytics department for two different managed Medicaid plans, claims data was our bread and butter. We had best of breed systems, ETL, a data warehouse, data marts and a team of well-versed analysts. We were able to create cost and utilization reports, identify our high flyers, look at the performance of our provider network through Healthcare Effectiveness Data and Information Set (HEDIS) measures, and even do risk prediction with a set of claims-based tools.
However, that was back when we paid fee for service, and lived in a largely paper-based clinical world. Even though our internal team of analysts generated our HEDIS measures, we still needed to contract nurses to do the chart reviews for the hybrid measures.
We had monthly meetings with our chief actuary to pull data to figure out our IBNR (incurred but not reported), otherwise known as the claims lag. Unfortunately, a lot of our reporting was skewed by the claims lag, and although the data was helpful, it was like driving the car while looking in the rear view mirror.
We are now in the era of electronic health records (EHR), MACRA and a plethora of digital clinical data, which means we can take advantage of what happens today, sometimes in real-time. With the advent of value-based payment models, where healthcare organizations work to improve outcomes at the same or lower cost, the need to know what happens today becomes an imperative.
As we meet with payers across the country, the forward leaning organizations have started to think about how to integrate clinical data into their overall strategy. Many of the health plans realize that sharing clinical and claims data makes business sense in order to help provider networks succeed in taking on risk. However, delivery reform accompanied by payment reform is probably one of the industry’s greatest challenges to date, and going at it alone for any organization will be extremely labor-intensive.
In light of all this, how should a payer organization go about developing its clinical data strategy? First, leadership must use clinical data to determine which use cases best support the organization’s strategic agenda. Examples include:
Once you have outlined the use cases that will support your key strategies, the next step involves determining what clinical data you need and how you will get access to it. This often is the hardest part of the strategy. Although some clinical data may be easily accessible (like lab results or medication fills), getting data from EHRs requires both governance and technical acumen. The good news is that provider-payer collaboration continues to accelerate. We have recently been involved in a number of these conversations, helping our clients and prospects think through their strategy and develop a plan to bring in the key clinical data they need. For payers that don’t have a clinical data strategy yet, we suggest they start thinking about it soon.
Lynda Rowe is Senior Advisor for Value-Based Markets at InterSystems, and has for two decades held senior-level positions in health information technology. She was most recently an executive in the health market at Booz Allen Hamilton, where she led a number of consulting projects for the Centers for Medicare and Medicaid and the Office of the National Coordinator within HHS. She provided leadership for quality measurement, health information technology use and adoption, health information exchange, interoperability and standards, and meaningful use engagements. She is currently vice chairman of the board of directors at Family Health Center in Worcester. Ms. Rowe continues to focus on the advancement of interoperability, technology use and adoption and government policy through various workgroups and task forces.
This article represents the views of the author, not America’s Health Insurance Plans (AHIP). The publication, distribution or posting of this article by AHIP does not constitute a guaranty of any product or service by AHIP.