Blog banner

The Truven Health Blog


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


A Data Scientist Thinks About Population Health Management


By Anne Fischer/Wednesday, August 24, 2016

(The Truven Health Advanced Analytics team is tasked with building new and differentiating analytic methods. Asked to explain some interesting new analytics that are important for managing populations, the Advanced Analytics team wanted first to explain how they’re thinking about Population Health Management.)

What is Population Health Management (PHM)? Much like the adage about the blind men and the elephant, Population Health Management can mean completely different things to different audiences. Hospital systems, practitioners, government, and private insurers all have different interpretations of what the term means. And, in fact, its implications are very different to each of these players.

For most health systems, PHM represents a complete paradigm shift from their traditional way of doing business. Think of it like this: Imagine you own an auto-repair business. Perhaps you have a single facility, perhaps a chain of facilities. You are generally responsible for fixing a car when it’s damaged, and perhaps also performing routine maintenance on that vehicle. Now imagine you are being told that:

  • You are no longer simply responsible for the car when it is in your shop, but you are responsible for the car’s general care and maintenance for its lifetime.
  • The insurance company is no longer paying for the specific services you provide, they are paying you based on the overall “health” of the cars that you service. You now need to know what happens to that car outside the walls of your facilities.
  • You are no longer simply repairing the car when it needs it, you are being paid to keep the car “healthy” and out of your repair shop.

Imagine how foreign that would seem. You have no information about the drivers of the car other than what you can gather publically. You have no idea what kind of driving record a person has, what kind of routine maintenance they perform on their car (except that which happens to occur in one of your shops), or what kinds of roads they drive on. In short, you have no knowledge of what kind of risk they bring to the table.

Hospital systems are in this situation. Historically, they have not needed to know much about their patients outside of what occurs within their facilities. They don’t have much information on where their patients are seeking care outside of their facilities, what kind of preventive care they are taking, what their social determinants of health are, nor how risky each patient is in terms of lifestyle and overall health, and they don’t have any input to their patients’ health benefit programs.

Now imagine you are the auto mechanic. Your repair shop owner is now asking you to understand the entire spectrum of a given vehicle you are servicing. Perhaps your specialty is body work, but you have to start thinking about the gas mileage and the health of the exhaust system in every car you see. Similarly, practitioners – particularly those who are not primary care physicians and are not used to thinking about “the whole patient” – struggle with the concept of population health because their focus is typically on one patient and one problem at a time.

Taking the analogy further, imagine you are the auto insurer (payer). You have historically managed payment for all the expenses for a given driver (and adjusted your rates to that driver based on their record/perceived risk). However, in this analogy as a healthcare insurer, your ability to refuse coverage to someone is diminishing, and your ability to assess risk is out of date, given that all drivers seem to be getting progressively worse and consequently more expensive. You are eager to shift some of that payment risk to the auto mechanics who are far more “hands on” with the cars, but there is no framework in which to plan and agree to terms. Plus you are still expected to maintain the risk for random “Acts of Nature” such as trees falling on cars, lightning strikes, and accidents caused by others. You are used to thinking about risk stratification and management at the group level, less so at the individual level.

Finally, imagine that you are the civil engineer responsible for designing the infrastructure on which the cars travel. You design roads to accommodate certain volumes, speeds, and types of vehicles, and support laws to enforce speed limits and construction zones. (Besides being the largest healthcare payer, this is the other role government plays in healthcare.) But now you’re being asked to help understand and contribute to improving the overall “health” of the vehicles on your roads, to do this in a way that minimizes the frequency and scope of needed repairs, and to do it all on a reduced budget. Oh, and at the same time, you have to be thinking about how to ensure safe roadways and service for new kinds of cars – self driving, connected, and beyond. . .

So how can Truven Health help? Our job as the analytics specialists is to help provide the information needed to expand the view of patients, and to present the information so that it’s actionable. Providing information on the full spectrum of care, even for something as specific as a surgical patient receiving a joint replacement (as our Bundled Care consultants do), can be invaluable in helping facilities, practitioners and payers understand the downstream implications of the care that is delivered. Helping them understand which patients are at high risk for “collision” (such as our new Risk of Hospitalization models) can lead to timely, cost-effective interventions. Identifying which segments of the population could most benefit from management (such as our forthcoming population classification method) can help focus activities for guiding patients and members towards health and well-being. Bringing valuable analytics to life can only happen if we first understand where our clients are coming from, and second, where they need to go to continue to be successful.

In coming blog posts, I will offer insights into the work of data scientists and into the analytics we are developing to help our clients continue to be successful.

 

Anne Fischer
Senior Director, Advanced Analytics


How Ready Are You for Value Based Payments?


By Truven Staff/Tuesday, August 16, 2016

There is a great deal of discussion and analysis about the shift to value based care as healthcare payers – employers and health plans -- contemplate new models of care. The Department of Health and Human Services (HHS) is already driving the change – by setting a goal that 30 percent of fee-for-service Medicare payments be tied to quality or value through alternative payment models (such as bundled payment arrangements) by the end of this year, and 50 percent by the end of 2018. Is your organization ready to make the move?

Truven Health has been consulting with payers on everything from their payment strategy to their risk tolerance, and we’ve learned that organizations are in varying stages in their journey to value based payments. Some are very far along, some are just starting, and others are unsure of where to start. In helping payers think about their journey to value-based care, we’ve developed some guidelines on how to begin.

If your organization is just beginning the journey, we recommend you ask yourself a few key questions: 

     What are our biggest opportunities and challenges? Have we validated potential financial and operational risks?

     Do we have adequate market and volume to justify the investment and minimize risk?

     How are we aligning with physicians to support adoption and population health management needs?

     Does our approach support our identified value based payment model strategy and objectives?

     Is our strategy agile and sustainable as new models continue to emerge?

A thorough assessment of your readiness for a new payment strategy should include:

     Analysis of your proposed payment model, including design implications, incentive structures, quality, provider alignment, and integration

     Evaluation of your opportunities, challenges, and readiness to implement bundled payment definitions and pricing

     Review of your performance measurement reporting, including gaps and an impact analysis

     Assessment of data feed adequacy, quality, and clinical and financial implications

The journey to value-based care and payment will not happen overnight. Payers and providers will need to collaborate, learn, and adjust their approach to various approaches before finding their best fit. The key is to have information and analytics to support the process, and a partner with holistic and deep experience across the entire claims and revenue lifecycle. 

For answers to your questions about value-based payments, or for help devising a payment strategy, contact us at payersolutions@truvenhealth.com.


EDGE Server Data Submissions: Do You Need Help?


By Bryan Briegel/Thursday, July 7, 2016



Now that health plans have a couple of years of EDGE server data submissions under their belts, it’s a great time to step back and evaluate how your organization did.

We think a few key questions to ask are:

  • How well did our approach to EDGE work?
  • Did we have clean data to optimize our risk adjustment?
  • Were we able to respond to the changes in CMS requirements in a timely and effective manner?
  • What operational improvements do we need to make?

  • The fact is, many health plans — busy serving their members by providing quality care at a reasonable cost — simply don’t have the proper resources or experience in place to complete the arduous tasks needed to comply with the Premium Stabilization Programs. The EDGE server requirements are challenging — and missteps in meeting them have led to disappointing results, including leaving reinsurance dollars and understated risk scores on the table . Even large health plans with corporate supports in place have been challenged to meet the requirements.

If you think there’s a potential for improvement, now is the time to consider a new plan for your EDGE server submissions. Should you continue to go it alone or stick with your current TPA? Before you decide, consider all the things that a proper EDGE server process should entail.

Your solution should give you:

  • On-time, accurate submissions
  • Dynamic data management services, with constant updating to meet CMS changes
  • At a minimum, quarterly analytic reporting
  • Support staff to keep current with CMS changes and respond to their EDGE server inquiries and mandated server updates
  • Peace of mind and the ability to focus internal resources  attending to your day-to-day responsibilities

If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, so you can get back to the business of offering quality health care. Contact us to learn more.


Bryan Briegel, Healthcare Reform Solutions Specialist 
Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations



Here’s What you Missed at AHIP Institute 2016


By Truven Staff/Wednesday, June 29, 2016

Last week, representatives from Truven Health Analytics, an IBM Company, and nearly 3,000 other healthcare professionals attended AHIP Institute 2016 in Las Vegas, NV to learn from health plan industry leaders, see the newest products and services, and get an idea of what’s ahead in healthcare.

Here’s what you missed from Truven Health at this year’s AHIP Institute:

  1. Some things just work well together: A Toast to Truven Health Analytics and IBM Watson Health - During the opening night reception, Truven Health Analytics and IBM Watson Health celebrated our new relationship: Truven Health is now a wholly owned subsidiary of IBM Watson Health.

  2. Custom LEGO® Bridge Build - Our booth included a custom LEGO bridge build to show how our portable analytics solution can bridge the gap between your enterprise data warehouse and the answers you need. Watch our video for more information on our portable analytics solution.

  3. Truven Health Concurrent Session: Bundled Payments: Evaluating the Opportunities for Your Business -  During our concurrent session on Thursday, June 16, Truven Health experts Kevin Ruane and David Jackson discussed the experiences of payers and providers in various stages of implementing bundled payments. They also reviewed methods used to determine preparedness, how to evaluate opportunities and risks, and key metrics for success. 

If you missed our session at AHIP Institute, the presentation will also be included in our upcoming AHIP webinar. Contact us to register.

Contact us for more information on AHIP Institute, or to find out more about our solutions. 


2015 Was a Big Year for Bundled Payments. Here’s Why.


By Tom Halvorson/Tuesday, June 28, 2016

On November 16, 2015, CMS announced the Final Rule for the Comprehensive Care for Joint Replacement (CJR) model, instituting mandatory bundled payments for hip and knee total joint replacement episodes for hospitals in select geographies across the country. The bundles would cover all related services from inpatient admission to 90 days after discharge.

Unlike the earlier bundled payment initiatives, in which hospitals success was defined by their ability to reduce episode spending from historic levels, success under the CJR program is based on a health system’s ability to become and remain an efficient provider of joint replacement episodes in their region.

Case Study: Bundled Payments in Action

Although the new CJR payment model will continue for five performance periods, through December 31, 2020, it’s important for health systems to evaluate and monitor their CJR deployment as soon as possible. To position one regional health plan’s health system for success, Truven Health Analytics provided a high-level assessment, implementation services, and ongoing monitoring support. With the assessment, Truven Health:

●      Analyzed historical spending and utilization of post-acute service trends

●      Evaluated historical utilization of post-acute services against regional benchmarks using Truven Health MarketScan® data and the Medicare Standard Analytical File

●      Analyzed skilled nursing providers used by CJR patients

●      Performed a variation analysis of high-volume surgeons’ spend, utilization of post-acute services, and readmissions

●      Forecasted annual financial wins and losses

●      Projected performance using current internal data

As a result of the Truven Health review and modeling, the health system was able to develop and implement a standard care pathway to address variation in post-acute care, achieve consensus from the physician practice on the newly formed pathway, institute discharge planning protocols, and define a clear post-acute network. These efforts allowed the system to reduce single joint replacement costs by $400 and bilateral joint replacements by $3700.

How Ready Are you to Implement Bundled Payment Pricing?

For answers to your questions about bundled payments, or for help devising a bundling strategy, contact us at payersolutions@truvenhealth.com.

Tom Halvorson
Director, Analytic Consulting

*These results are a statistical narrative represented by a number of Truven Health client projects

 


RSS