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The Truven Health Blog


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


Enterprise-Wide View of Population Health Can Lead to More Value


By Rebecca Molesworth/Thursday, July 31, 2014
The 2014 “Most Wired” hospitals from Health and Health Networks annual survey of hospitals are focused on supporting their organization’s initiatives to drive analytics for population health management. Rightfully so, they are looking at the extreme demands on their IT departments, their lower margins and the magnitude of change occurring around them to make deliberate and specific steps toward managing their populations’ health. Many of these experiments are happening in very discrete and targeted ways, employing resources carefully, all of which makes a vast amount of sense in the current healthcare landscape. The danger of this approach, however, is a myopic view of population health by the stakeholders that fails to deliver true organizational impact.

Equally critical to husbanding resources appropriately with these new endeavors is the need to have an enterprise view of how these strategies will play out over the whole network over time. A synchronized organizational strategy that involves all key stakeholders will guide resource decisions that will be critical in preventing future costly rework. A common aggregation of population health needs across stakeholders will often uncover the requirement to have a longitudinal view of patient data. This ensures common patient counts in the most basic of analytics, as well as more complex questions of exclusions, duplicative information and which measures matter the most to ensure compliance with quality, utilization and outcomes goals for the whole enterprise. Furthermore, the level of investment required for an organization to fully liberate the vast sums of useful data currently locked in provider facilities and data silos is a strategic choice better suited to serving multiple purposes to ensure that the investment reaps its potential economic value and supports enterprise-wide decisions.

Working with limited data sets in the short-term to quickly get an experiment up and running or focusing on meeting one Centers for Medicare & Medicaid Services (CMS) requirement must be in line with the long-term goal of having financial and operational metrics that are in sync, both for the clinician leveraging that data for his or her own practice as well as the CFO looking at the outcomes across a program, as an example. Neglecting to take time to sort through these universal data needs in the planning of a program can lead to frustration and a potential lack of trust in the data which will in turn severely challenge key stakeholder engagement.

It’s a simple idea that is much easier said than done in the real world.

A fully vetted strategy that is supported by partners with real-world experience on the cost/benefit choices to be made during these kinds of population health analytics efforts, will go a long way to set an organization on a track, break population health into manageable pieces, and ensure that the whole organization ultimately moves forward together. Without this alignment and focus, limited resources can be lost to isolated pet projects that fail to impact overall patient outcomes or the organization’s bottom line.

Rebecca Molesworth
Manager, Solution Management

Pediatric Emergency Department Quality of Care: A Focus on Pharmacists and Drug Therapy


By Linda Elbers/Wednesday, July 23, 2014
Linda Elbers imageListening to National Public Radio (NPR) on the way to work recently, I heard a very interesting report about Children’s Medical Center in Dallas incorporating full-time emergency department (ED) pharmacists to ensure appropriate and optimal drug therapy is provided to their patients in the ED setting. As a pediatric-trained pharmacist, anytime I hear about organizations embracing the pharmacists’ role in doing even more to support safe and effective drug therapy in this patient population, it’s particularly exciting. And this information was timely, as my colleague Tina Moen, Chief Clinical Officer for Truven Health, just shared her thoughts about the expanding role of the pharmacist in a recent blog post. While pharmacists have known for some time that we have a great deal to contribute to improving patient safety, it’s wonderful to know that others are taking notice now more than ever.

Important, key organizations such as the American Academy of Pediatrics (AAP) and Emergency Medical Services for Children (EMSC) are focusing much time and effort on improving pediatric services in U.S. emergency departments. This isn’t just for pediatric-specific emergency departments, but for any ED that will see neonatal and/or pediatric patients, whether frequently or infrequently. It’s estimated that up to 25 percent of all ED visits in the U.S. are pediatric patients, and approximately 90 percent of children’s visits to the ED are in non-pediatric hospitals.

EMSC – an organization that works to promote emergency medical services (EMS) and trauma system development at the local, state, regional, and national levels to adequately prepare for care of children – has developed 60 ED pediatric performance measures that comprehensively cover a broad range of assessable activities related to pediatric emergency care. I recommend visiting www.emscnrc.org to learn more about this resource.

As you would expect, some of the 60 EMSC performance measures and their potential outcomes are associated with drug therapy. For example, “timely treatment with anti-epileptic drugs for patients in status epilepticus” is one of the performance measures. The numerator for this performance measure is the number of patients who received an anti-epileptic drug within 10 minutes of arrival, and the required data elements include medication name, patient arrival time, and medication receipt time. As a pharmacist, however, there are many additional steps in this arena to further care and improve outcomes, simply by applying a medication-focused lens. For instance, while the patient may receive an anti-epileptic medication within 10 minutes of arrival, to assess the efficacy of the therapy, we need to know additional information and should do further assessment, including asking:
  • Did the medication provided actually resolve the seizure?
  • Was the right drug administered for this patient?
  • Was the correct dose prescribed?
  • What resource was used to determine the dose? How was it calculated?
  • Was it administered correctly?
Without this further evaluation of medication practice, it’s difficult to affect outcomes and quality.

Other EMSC performance measures address pain management and sedation (e.g., the effective pediatric procedural sedation, treating and reassessing pain). While there are criteria for assessing adequate sedation or adequate pain relief, again, as a pharmacist, it’s clear that more information would lead to marked advancement in patient care. For example, if there were additional documentation required regarding the drug(s) used, the dose(s) used, the route of administration, etc., this would help to assess outcomes. As such, the additional detail can assist in developing protocols to assure adequate sedation or pain control in the majority of situations – a problem patients across the country routine indicate is an area of patient dissatisfaction in HCAHPS results each year. And this additional detail could identify inconsistencies or inadequate drug therapy, including drug dosing that leads to inadequate/ineffective sedation or pain control.

As the NPR story pointed out, not all hospitals will have the resources to hire a full-time, or even a part-time, ED pharmacist to manage pediatric drug therapy in the ED setting. However, a pharmacist’s focus and input have the potential to contribute greatly to improved pediatric emergency care. What has your ED done to be better prepared to treat children? How are pharmacists contributing to better emergency care? Let us know what first steps you have taken, or would like to take, to help your organization and others meet the mark for pediatric and neonatal care in the ED.

Contact me on LinkedIn.

Linda Elbers, Pharm.D.
Clinical Solution Advisor Neonatal/Pediatric Evidence-Based Practice

Using Big Data to Improve Quality and Reduce Costs


By Michael L. Taylor/Wednesday, July 16, 2014
Mike Taylor imageA new report on potential uses of big data for controlling cost in the hospital setting has just been published. The report, from Brigham and Women’s Hospital in Boston, appeared in the July 2014 edition of Health Affairs. Six areas of potential benefit were discussed:

  • High-cost patients
  • Preventable readmissions
  • Triage upon hospital admission
  • Decompensation of clinical condition while in the hospital
  • Adverse events, particularly renal failure, infections, and adverse drug reactions
  • Treatment optimization for those with chronic disease involving multiple organs
As the authors point out, these are six key areas for intervention to lower healthcare costs in the hospital setting, and using more diverse data sources to analyze these opportunities will be useful.

As I reflect on this report, it strikes me that this type of report would have probably not been published several years ago. Healthcare reform, particularly changes in the payment methodology, is driving this type of research. I understand the need to minimize the healthcare spend and agree these are six key areas for research. But, in my opinion, the more important clinical issue is the improvement in the quality of care and probable saving of lives from better care. This is the real issue and opportunity.

All six of these areas are a result of missed opportunities to improve care. These areas are inter-related: high-cost patients are often a result of those who are readmitted multiple times for the same condition, suffer complications, are inappropriately triaged, and have missed diagnoses or have adverse events. Some of these problems can be prevented medically, but some of these issues have broader root causes. Take readmissions – many cases are due to socioeconomic factors such as inability to pay for medications, poor access to outpatient healthcare, or inability to pay for home care. Doctors and hospitals have historically not been paid to consider and manage these non-medical factors that lead to increased medical cost. While no physician wants complications to develop in their patients, hospitals and physicians have never before been penalized if this happened, so there has not been a focus on preventing these complications. New payment incentives are driving these changes and new approaches to care are developing. The promise of higher pay for better value in healthcare of populations, not for providing more services to individuals, is leading to new solutions in these six areas. “Big data,” meaning information about socioeconomic factors, living situations and other new data sources, and then using these data in predictive algorithms, will improve our ability to care for populations, not just treat individuals. 

At Truven Health Analytics, we use data to understand high-cost medical care. As we work with the payers of healthcare, especially large employers, part of our study is high-cost patients. I consistently find these cases to be complex, often involving advanced cancer cases or complicated heart failure cases. Closer oversight of these patients, team-based care, and better methods to predict and manage complications is warranted in many of these cases. Accountable Care Organizations (ACOs), with a patient-centered focus and a population health strategy, are promising new approaches to improving care. The tragedy of many of these cases however, is the missed opportunity to prevent these cases from ever occurring. If screening guidelines were followed more universally, advanced colon cancer would almost never happen. Heart failure is usually due to multiple heart attacks that could be prevented by paying closer attention to decreasing risk factors. Not all high-cost cases can be prevented, but many could be avoided.

Why, as a nation, are we not doing a better job in managing the health of our population? The most obvious answer is because we aren’t focusing on and prioritizing disease prevention among our population. Up to 70% of healthcare costs are due to preventable disease, but our healthcare system hasn’t been paid to focus on this issue. But change is apparent. The healthcare industry is undergoing more rapid change at this time than I’ve ever seen in my 30+ years of being a doctor. The new clear message is this: the way to manage costs is to improve the quality of care for entire populations, including new ways to prevent disease. Technology in the form of implementing integrated electronic health records, using more diverse data streams, re-designing healthcare delivery, and better predictive analytics are all tools to improve the quality of healthcare in the U.S. This is the right path to reduce costs.

Michael L. Taylor, MD, FACP
Chief Medical Office

Smart Use of Urgent Care Helps Consumers, Providers, and Payers Win


By Linda MacCracken/Tuesday, July 15, 2014
Linda MacCracken imageConsumers – people like us, our parents, and our children – wait an average of 19 days for an appointment with a family practice doctor, making healthcare difficult to obtain. When you can take three vacations in the time that you’ll wait to see a doctor, something is really wrong. The magic of the Internet – online Skype appointments and iPhone diagnostics – lacks assurance that something dire hasn’t been missed. This is why doctors train, get credentialed, and ‘practice.’

Providers with smart, extended footprints are doing more. Our data shows that over the next five years, demand for after-hours care in some markets can grow 35%, versus a 22% demand growth for overall Emergency Department (ED) care. The newly insured’s younger enrollees – those under 35 – will use the ED twice as often as when they were uninsured. Nationally, 62% of ED visits are urgent, suggesting that at least one in three can be seen elsewhere.  

Payers are concerned that 70% of ED visits are avoidable, and they can save the $1100/visit by redirecting ED patients to lower-cost sites, such as urgent care centers. Urgent care is right for patient demand, good for the provider access, and effective for payers seeking to contain costs.

Winning the race to profit from the demand for urgent care and improve patient experience calls for delivering the right service, in the right market, with the right access.

Linda MacCracken
VP, Advisory Services

Medicaid Program Integrity: Fighting Fraud in a Managed Care Environment


By David Nelson/Monday, July 14, 2014
David Nelson imageA recently published study by the Government Accounting Office identified a need for states to ramp up their efforts to assure Medicaid program integrity under managed care. Although a majority of Medicaid beneficiaries are now enrolled with managed care organizations (MCOs), and payments for those plans are growing at a faster rate than fee-for-service (FFS) expenditures, some states are just now beginning to shift their program integrity focus from FFS to managed care. 

Traditionally, Medicaid has fought FFS fraud, waste, abuse, and overpayment by applying edits and algorithms to claims in prepayment, and using data mining, investigation, and recovery modeling and analytics in post payment. More recently, Medicaid has stepped up fraud-prevention efforts by expanding the use of prepay predictive analytics and implementing provider credentialing and stringent ongoing provider surveillance, as required under the Affordable Care Act (ACA). 

Best-practice Medicaid agencies have increased their managed care program integrity efforts through more comprehensive oversight of their contracted MCOs. They are collecting and validating encounter data, which allows them to perform advanced analytics to find fraud, waste, and abuse, and they are performing checks to ensure proper Medicaid administration. These agencies examine the full continuum of managed care fraud and abuse vulnerabilities:
  • Traditional FFS issues, such as over-utilization and billing for unnecessary or unused services
  • FFS/Managed Care crossover issues, including double billing and payment for ineligible recipients, such as prisoners and those with certain medical conditions or who are enrolled in certain waiver programs
  • Managed care operational issues, such as inaccurate encounter claims, under-utilization, and cherry-picking patients
  • Managed care financial auditing to ensure that MCOs accurately account for and categorize costs incurred and capitation rates are premised upon correct information
Medicaid agencies need to be diligent stewards of their managed care contracts. While managed care adds new complexities and challenges for monitoring program integrity, the rapid growth in managed care enrollment adds to the urgency of putting in place effective oversight mechanisms. 

Critical Success Factors
As we look across best-practice Medicaid agencies, several critical success factors have been shown to produce significant results for the integrity of the program under managed care. Some of these critical success factors are:
  • Encounter data accuracy and completeness
  • Contract provisions and rules to support managed care payment integrity
  • Capitation payment review
  • Data analytics examining MCO services and comparing MCO utilization to FFS
  • Inter-MCO comparisons and analytics
  • Managed care organization auditing (both financial and operational)
By incorporating such success factors, Medicaid agencies can avoid common fraud, waste, and abuse pitfalls under managed care and improve the integrity of the program.

Truven Health Analytics™ has been helping managed care organizations in all of these dimensions for several years. Our experts have advised 20 states over the past 15 years about managed care encounter data strategy, and our program integrity experts have been delivering recoveries to Medicaid agencies for three decades. In fact, IDC MarketScape recently named us an industry leader in fraud, waste, and abuse solutions.*

For more information, please contact me at david.nelson@truvenhealth.com.

David Nelson
Vice President, Market Planning & Strategy

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