Crystal Run is able to incorporate patients' outside visits to providers, Spencer says, "but it's not easy. We require source documentation to satisfy measures. For example, we scan outside mammogram results into a directory that we can then report against. We don't take people's word for dates. We need to have the document."
Getting the initial claims data from CMS took three months, and then it takes another three or six months' worth of that data for it to become actionable, Spencer says.
Claims data on any one patient is also plagued by incurred but not reported claims. Until IBNR claims get processed through Medicare or other payers, a true picture of a patient's treatment is incomplete.
In light of this, it's important for all concerned to have realistic expectations of what population health analytics can achieve and when, Spencer says.
"Cost is a practical concern we all face in our day-to-day lives," he says. "You get more for more money, but as in all things, you have to be prudent. I don't know how you will be able to do business in the very near future without using some form of analytics. How will your quality measures be good enough to meet the 'gates' required for contracts? How will you know where you are or if you can grow and how? It has cost a lot of money—money that's been spent over a long period of time. The cost is into the low millions.
"That said," Spencer adds, "we are able to take advantage of newer payment models that reward us not just for healthcare, but outcomes. We can potentially get paid for not doing anything—the PMPM that can be negotiated when you show you are doing a good job managing a population of patients."
Analytics in the ambulatory practice
Gastroenterologist Tom M. Deas Jr., MD, practices as part of North Texas Specialty Physicians based in Fort Worth, an independent physician association comprising nearly 600 family and specialty doctors. NTSP has its own health plan and has been managing Medicare patients at risk for several years.
NTSP provided initial funding for a population health analytics firm, Sandlot Solutions, which has now been spun out as a separate company, although NTSP remains a part owner and Deas also serves as Sandlot's chief medical officer. NTSP uses Sandlot's analytics software to manage 80,000 at-risk lives, Deas says.
"Without some of the information technology to identify those patients based on their illnesses, comorbid illnesses, their severity of illness, who their physicians are, where they've been going to get their care, and being able to manage the whole spectrum of the care, you're at a serious disadvantage," Deas says.
Sandlot's technology combines claims and clinical data into a robust patient data warehouse that helps meet some of the quality measures required to be an ACO, says Deas. "With the ACO, no matter how much money you save, you don't get a dime of it if you haven't met all the quality measures, so if we fall short in that area, it's economically not good and it's not good for the patients."
By default, all Pioneer ACOs received three years of Medicare claims data. Getting the data into the warehouse requires overcoming some well-known healthcare IT issues, such as reconciling that claims data with an enterprise master-patient index, eliminating duplicates, and general patient-matching issues, Deas notes.
Once that was done, NTSP could concentrate on using Sandlot's analytics to spot and eliminate wasteful services, as such home visits for patients lacking a medical necessity for such visits, Deas says. Analytics-driven interventions can manage a few hundred overutilizers of services as outpatients, focusing care management on them, he adds.
After a year's effort, NTSP has bent its cost curve through these efforts to the tune of $50 per member per month, Deas says. "Now we're not completely there," he cautions. "It's an incremental process, because you're not only doing management, but you're changing behaviors also. You're trying to get patients aligned with the primary care physician, trying to move them from one source of care that was maybe excessive utilization to another."
Deas says measuring the ROI of analytics technology remains elusive.
"A lot of people think they just buy an analytics tool and a data warehouse and an HIE and it'll sit there and solve their problems," he says. "That is not the case. You have to have human folks using that tool to manage the care of patients, to lower the cost and improve the quality. It's like me asking you how much more efficient are you with a smartphone than you were five years ago with whatever version of phone you had then. You can't answer that question. All you know, it's just one part of what's happened in the past five years to make you more efficient."
It no doubt helps that NTSP's executive director, Karen van Wagner, has a PhD in statistics, giving the organization added expertise to quantify results as they emerge.
Analytics technology is just beginning to make its impact felt in population health management. Careful consideration of products, objectives, workflows, and business conditions will steer providers through potential pitfalls, but the effort is considerable and the challenge to healthcare leadership is ongoing.
"Among the things that made these changes successful is an IT infrastructure that supports population health management and care management," Deas says. "We still have to throw a fair amount of resources—human resources—at it to make it work."
This article appears in the November issue of HealthLeaders magazine.