There are opportunities for immediate financial benefits as well. Rush has built a surveillance application that allows executives to look at all claims across the network and see if they were paid as expected. "It allows us to calculate an expected payment," Estes explains. "This application allows us to aggregate all the issues and work with payers on behalf of all our members at the same time. For instance, here are the 200 claims we found that were not paid in the right way. That is a big benefit to any physician practice because it doesn't force them to chase underpays one by one."
Such underpays are small individually but big in the aggregate, he stresses. In addition, executives can look into productivity and outcomes both organizationwide and on the individual level. More important over time will be its ability to allow executives to monitor growth in terms of new patients over time, and per capita cost.
"Those will be two things important for me to focus on," Estes says. "If we want to take population management and get ready for
ACOs, whatever those end up being, or direct contracting or direct-to-consumer work, we need to focus on clinical data and change how care is delivered to reduce costs and improve outcomes."
Graduating from process to prevention
Ryan Leslie says success with population health strategies will hinge on enabling effective decision-making by clinicians, both in real time and for planning purposes. Leslie is vice president of analytics and health economics at Seton Healthcare Family, a 10-hospital system based in Austin, Texas, which has been working recently with IBM on the problem. Using the same software components that run the famous Watson computer of Jeopardy! fame, Seton is helping its clinicians identify patients who would benefit most from extra attention following discharge. The program started with congestive heart failure patients, and Leslie hopes to expand to other disease states.
"A lot of it is about enabling decision-making," he says. "It's taking the whole universe of information we have and cutting out what's extraneous and giving clinicians the information they need to make decisions."
Taking unstructured clinical information and connecting that with billing or administrative information and social demographic information, "you start connecting all those things together and you get a more complete picture of the patient as a person, rather than as a recipient of a bill," he says. "That's been the exciting thing recently. You realize that a patients' success or failure may not have to do with the care plan details or the clinical attributes of the patient as much as the social attributes."