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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Sharing Quality Insights With Providers


By Michael L. Taylor/Tuesday, August 18, 2015

BlueCross/Blue Shield of Illinois (BCBSIL) recently announced a new data sharing arrangement with the DuPage Medical Group, a large independently owned physician medical group in the Chicago area.  This arrangement calls for BCBSIL to share its medical claims and (unnamed) quality data with physicians of the DuPage Medical Group. These data will help the physicians better understand the healthcare services their patients are receiving outside the DuPage clinic walls, including the quantity and quality of care their patients are receiving from non-DuPage physicians.

This information is becoming more important to physicians as their reimbursement for services provided is increasingly tied to patient outcomes. The Blues organization also announced their goal of having 75% of their Illinois market to be paid on the basis of improved quality and lower costs within the next 5 years. This trend has been driven by the Center for Medicare and Medicaid Services (CMS), with HHS Secretary Burwell announcing the 2018 CMS target of 50% of payments based on value, and 95% of fee for service payments having a quality component as part of the payment.

We are likely to see many other arrangements similar to the BCBSI deal in the commercial market over the coming months and years. The country is gradually realizing that fee for service payment arrangements become an incentive to provide more care, while value based payment models incent higher quality care.

Rewarding higher quality care and penalizing poorer quality care is a step in the right direction, and for certain elements of care, quality can be readily measured. For example, for most common surgical procedures, standards have been developed to measure complications, length of stay, hospital-induced infections, mortality and other discrete endpoints. It may not be as straightforward to measure quality of care in the primary care settings, but quality can be measured.

An interesting article published in 2012 in The New England Journal of Medicine offered a framework for measuring system-related quality of care. The authors suggested 6 domains of quality that could be measured:

  1. Patient safety
  2. Patient and caregiver-centered experiences and outcomes
  3. Care coordination
  4. Clinical care
  5. Population and community health
  6. Efficiency and cost reduction

This framework may be well suited to measure the effectiveness and quality of care being delivered in the primary care setting, and these efforts need to be supported. Hopefully this BCBSIL and DuPage Medical Group partnership will spur other large carriers to try similar arrangements with hospitals and physicians. Combining cost metrics with quality metrics can deliver the type of transparency that is lacking in today’s fee for service world. The payer community has been asking for this type of transparency, and consumers are now asking for the same information.

I’m hopeful the metrics agreed upon will be shared publicly.  It will be interesting to follow this new arrangement over time to see if the quality metrics are robust, and if patient care actually improves.

Michael L. Taylor, MD, FACP
Chief Medical Officer

 


No Organization Likes Surprises – Especially When it Comes to PBM Contracts


By Marie Bowker/Monday, August 10, 2015

CVS Health Corp., the second largest pharmacy chain in the country, is the latest company involved in a class-action lawsuit for allegedly overcharging patients for generic prescription drugs.


Though CVS has yet to make a public statement about the claim because they haven’t been officially served with the lawsuit, company spokesman Michael DeAngelis did state that co-pays are determined by a patient's prescription coverage plan, not by the pharmacy, and that a similar lawsuit in Massachusetts was dismissed.


Plan sponsors don’t always prevail in these kinds of complaints, but situations like this are exactly why you don’t want to use a pharmacy benefit manager’s (PBM’s) standard contact language.


The details around factors such as discount programs and “usual and customary” pricing can make all the difference in how much you and your plan members pay for prescription drugs.


For example, your PBM contract should include language that the PBM will charge you for the lowest of the following pharmacy network claims (less member copayments or deductibles):

  • Participating pharmacies’ usual & customary (U&C) price
  • AWP discount (ingredient cost) plus the guaranteed dispensing fee, if applicable, or
  • Maximum allowable cost (MAC) plus the guaranteed dispensing fee, if applicable

Ensure your PBM contract protects your interests.


Health Plans, download these best practices for contracting with your PBM, visit our website or contact us here


Employers, download these best practices for contracting with your PBM, visit our website or contact us here


Marie Bowker
Senior Director, Payment Integrity


Data-Driven Healthcare Decisions

Two Minutes With Jen Huyck, Vice President Analytics and Consulting, Truven Health Analytics


By Jennifer Huyck/Friday, August 07, 2015

 

Healthcare payers are turning to data and analytics for a variety of reasons, but the most prominent is the impact of healthcare reform. The evolving healthcare landscape has put a lot of pressure on employers, health plans, and providers alike. And with that, from an employer perspective, the C-suite is putting a lot of pressure on their health benefits group, who in turn is putting more pressure on their health plans to understand the ROI or VOI for every dollar spent. 

Payers Have Different Needs From Data Analytics and Reporting 

When payers are thinking about data analytics and reporting, they have a variety of needs:

  • They’re looking for benchmarking information to help show how they compare to others and where opportunities are. 
  • They’re looking for flexibility when it comes to reporting. Different audiences have different needs. How you report information back to the C-suite might be very different from how you report to a case manager or to someone in the health benefits department. Having the ability to show data and information in different ways is essential. 

Experience is important both from a data management as well as a consultative perspective. When you think of data management, you want to make sure your partner understands the importance of data accuracy and takes it seriously in order to ensure the data you put in is as accurate as the data you get out. 

How Do Payers Use Advantage Suite from Truven Health? 

Advantage Suite is our flagship product. It allows users to take disparate data sources and integrate them together. 

When using Advantage Suite, users are able to take a variety of data sources, such as medical, prescription drug, and eligibility information, as well as data sources that include health risk assessment information, disease management, and care management and integrate it together so that they really can look at cost and quality as well as provider information to make decisions. The power of the Advantage Suite data warehouse is that you have the ability to get down to claim level analysis, as well as summary level analysis, executive reporting, and dashboard information. 

As you look at data, it’s most important to understand what that data means. If you can get the right data to answer the good and bad news as well as the so and now what, then you will make the right decisions for your company and for your employees. 

Learn how to put your data to work with Advantage Suite®. 

Health Plans, please visit our website here or contact us here

Employers, please visit our website here or contact us here.


Using Integrated Performance Analysis to Support Merger and Acquisition Decisions: Evaluating Market Opportunities in the Value-based Care Era


By Truven Staff/Monday, July 13, 2015

The Affordable Care Act (ACA), value-based care, and new reimbursement programs are forcing hospitals and health systems to look at organizational performance holistically, at the point where clinical, operational and financial measures of quality and cost intersect.

 

These shifts in how care is delivered and reimbursed greatly affect how hospitals and health systems succeed. The fee-for-service model rewards volume, and if an organization manages costs, it can thrive on sheer numbers. The value-based care model is more complicated. Hospitals and health systems will make money on the services where they provide high-quality care, at a lower cost, to a larger percentage of the population than the competition, where they control (or effectively manage) the continuum of care. As a result, mergers and acquisitions are more prevalent. But this brings up an important question: How do you determine your greatest competitive advantages – clinically and financially – as you contemplate a merger or acquisition or integrate service lines after the transaction?

 

Having an understanding of these critical data points can help you make the most informed decisions possible, and positively affect the quality of care delivered and the financial results associated with care. Hospitals that provide high-quality care will grow their market share, because they will become the hospital of choice for individual healthcare purchasers and larger purchasers, like large employers or payers. So, by strengthening the relationship between market intelligence, quality, and efficiency measures, competitive advantages can fall in line.

 

The Integrated Market Assessment, a Truven Health analytic service offering, helps hospitals and health systems take advantage of all strengths – market-specific competitive advantages, clinical, and financial – when investing in capital projects and strategic service lines. The program is designed to help you intelligently respond to increasing competitive pressures, partnering, and market opportunities, by combining market intelligence (traditional volume and market share indicators) with quality and efficiency measures.

 

Integrated Market Assessments help Providers address challenges such as:

·         Merger and acquisition optimization (before and after)

·         Competitive market analysis

·         Quality and efficiency metric identification

·         Market trend and target population identification

·         Financial strength, stability, and sustainability metrics comparison (reported to the Centers for Medicare & Medicaid Services)


For more information about the Integrated Market Assessment, please contact us by phone at 1.800.525.9083, option 4 or by email at ProviderSolutions@truvenhealth.com.

 

 


Implementing a Successful Consumer-Directed Health Plan


By Emily Kelly/Monday, June 29, 2015

Consumer Directed Health Plans (CDHPs) are quickly becoming a popular benefit option for U.S. employers. These high-deductible plans are one of the fastest-growing benefit options for employees. To explore their effectiveness, we conducted a study using the MarketScan® Commercial Claims Database. The study closely matched members enrolled in a CDHP to members continuously enrolled in a non-CDHP, and evaluated healthcare costs and utilization over three years. We found a direct link between CDHPs and lower healthcare costs. On average, CDHP enrollees incurred $457–$532 less per member per year.

But these savings might come with consequences. Utilization rates were lower among CDHPs for a wide range of services — including professional visits, lab services, non-maternity admissions, and prescription drugs — suggesting that consumers may be reducing utilization across the board as opposed to simply avoiding unnecessary care. Of particular concern, members enrolled in CDHPs were less likely to receive any medical care for their existing chronic conditions than were their non-CDHP counterparts (based on a review of eight common conditions asthma, congestive heart failure, coronary artery disease, depression, diabetes, hypertension, low back disorders, and osteoarthritis).

Although the benefits of CDHPs are substantial, these arrangements need to be entered into carefully. It is important to recognize that a CDHP design could result in members not receiving recommended care — and that could lead to higher costs in the future. If your company currently offers or is contemplating a CDHP, we suggest that you consider the following:

  • Educate enrollees so they fully understand and take advantage of their benefits, specifically benefits of covered preventive services.
  • Engage CDHP members to ensure they are continuing to manage chronic conditions while enrolled in a CDHP. The study suggested CDHP members received less care for current chronic conditions and were less likely to be diagnosed with new chronic conditions.
  • Recognize that each employee is unique, so a CDHP might not be the best choice for all members. Help individuals choose the right plan based on their current health and their healthcare plan history.
  • Provide useful tools, such as cost calculators, to make it easier for members to access information on physician cost and quality. 

For the full study on the impact of CDHPs on cost, utilization and care, click here


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