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Using Claims Analytics to Improve Population Health

April 2, 2019 BY Alanna Moriarty

Using Claims Analytics to Improve Population Health

Population health management is vital to addressing the wellness needs of communities across the country. It requires both care coordination and consistent data collection. The omnipresence of electronic health record (EHR) systems further enables the collection and aggregation of essential patient information, which empowers healthcare leaders to act on chronic illness trends in their communities.

We’ve compiled a guide on how you can best leverage claims data from CMS and private payors to improve population health.

1. Find your population

Whether you’re targeting diabetes or COPD, you need to gather as much data as you can on your patient population. You can use commercial claims analytics to find the populations most affected by chronic illnesses, hospital-acquired conditions and infections, and other therapy areas.

Let's use diabetes as an example. By percentage, West Virginia has the greatest population of Medicare patients living with diabetes according to Definitive Healthcare’s visual dashboard. The state with the greatest hospital admissions due to diabetes, however, is Texas. Depending on the criteria you’re using to assess eligible patient populations, either of these states could be good candidates for new initiatives to manage and prevent diabetes.

Percentage of population with diabetes in West Virginia

Fig 1 Image from Definitive Healthcare’s visual dashboard on therapy area analytics for diabetes.

2. Analyze diagnosis, procedure, and Rx data

Once you’ve chosen a population to work with, you can leverage claims data to gain a deeper understanding of patient demographics. Some of the most relevant patient data could include age, comorbidities, and common inpatient procedures. Spotting trends in patient health information can be the key to improving population health. Knowing what these trends are in advance can also impact the implementation of solutions that address symptoms and comorbidities in addition to the primary diagnosis.

According to Definitive Healthcare’s CMS claims analytics, hyperlipidemia was the most commonly reported comorbidity for patients with diabetes in 2017. Hyperlipidemia, often referred to as high cholesterol, is the overabundance of fat particles in the blood. Left untreated, these fat particles can restrict blood flow and increase the risk of heart attacks and strokes in affected patients.

Common treatments for high cholesterol overlap with those for diabetes: medication, exercise, and a healthy diet. Knowing that diabetic patients also have higher risks of heart disease and stroke may affect physicians' approach in prescribing treatment plans and could also influence how frequently patients are tested for hyperlipidemia.

3. Establish intervention plan

Once you assess patient data, care providers can formulate a plan of action for physicians and local health centers. An effective plan should include regular check-ins with patients and providers to ensure care coordination, as well as attainable time-sensitive benchmarks. This ensures that any problems or questions are addressed, providers are held accountable, and new care plans are effective.

For accountable care organizations (ACOs), success measures are split into eight categories: three focusing on domain, and five on the patient population being monitored. The domain categories are patient experience, care coordination and patient safety, and preventative health. The population-based measures are for patients with or at risk for diabetes, hypertension, ischemic vascular disease, heart failure, and coronary disease.

4. Engage patients and providers

Throughout the duration of population health interventions, coordinators should be monitoring interactions between patients and providers. Studies show that patient engagement is linked to improved care outcomes and lower care costs. Engagement can be assessed through retroactive measures like HCAHPS satisfaction scores, where providers are rated on their ability to clearly and effectively communicate treatment plans with patients and those supporting them. The growing adoption of patient portal software can also increase patient communication with providers through websites accessible from any computer or mobile device.

Effective population health interventions should also directly involve integrated delivery networks (IDNs) and group purchasing organizations (GPOs). Due to their size, IDNs can coordinate care between a variety of healthcare organizations (HCOs) and offer a greater array of services than individual care sites alone. IDNs are also better equipped than individual HCOs to address social determinants of health, such as age and substance abuse, through management of or affiliation with specialty and home care services. Hospitals and IDNs can better manage their supply chains through affiliations with a GPO, lowering costs and reducing unnecessary purchases.

Fig 2 Data from Definitive Healthcare’s platform on hospital and IDN affiliations.

5. Support patients and providers

Make sure to check in on the progress of your population health improvement program to ensure it is progressing as expected. This includes measuring the financial impact of the initiative to stay on budget and record any effects on care costs. You should also be aware of service utilization rates to gain insights on whether patients are actually taking advantage of your population health improvement program. If any part of the program is not operating as anticipated, or if there is consistent feedback from patients and providers on ways to improve the execution of the initiative, you can adjust as needed to stay on track.

To learn more about how you can leverage medical and Rx claims analytics, watch our webinar on Using Claims Analytics to Win in Your Business, hosted by our own SVP of Strategy Kate Shamsuddin.

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