Making Data-Driven Decisions
“Talent makes a difference in helping us feel more comfortable making data-driven decisions. It keeps coming back to the talent to build the data, aggregate it, understand it, use it and then create actions around it to drive the performance you need to succeed.” Greg Warren
How should providers leverage data analytics to stem urgent care clinic or non-affiliated care site losses and the risk that comes with them?
JR: It always starts with the data and having the information to begin to understand what is occurring within your market. For example, what are the care and referral patterns in your system and in your market? Understanding these patterns should be coupled with an analysis of physician and episodic performance. That allows you to ask, when care is being directed to a specific site, practice, or facility, what are the outcomes of that care being managed in that setting? Is it the right setting? As a provider, you can coordinate care that is happening within your system, and with the right technology, you can monitor and manage referral activity in real time. This should lead to more efficient delivery of care and higher quality care, however performance analyses are important to prove this hypothesis. Another way to identify why patients may be leaving the system would be to ask yourself if this care is being managed more efficiently outside of your system and capabilities. Considering the Quadruple Aim, ask yourself if the outcomes, quality and costs are better. Ultimately, you want to understand where your populations are being cared for so you can act on external factors and provide better care management for the population.
Can an improved billing process lead to more sophisticated risk-based agreements between insurers and providers?
JR: First and foremost, we need to view this in the context of value-based care and consider the patient experience when it comes to billing. The amount of money spent on denials and the claims process between the payers and the providers is a very significant portion of premium costs that get passed down to patients. Anything we can do to become more efficient with the billing process will help with the total cost of care and ultimately improve the patient experience. Value-based care is already embedded in our billing processes today: coding standards exist and denials happen to ensure that the right care is happening in the right setting. When payers build a network of providers, it should be highperforming and high-quality, and the billing process exists to ensure patients are going to the highest-quality providers. The billing process was a precursor to value-based care.
GW: As payers help providers learn more about how to submit billing in ways that help the payers from a coding and risk adjustment standpoint, they’ll be able to make sure coding is based on policies that make the process more complete and thorough. This enables more synergies and smoother processes between parties, as well as fewer payment integrity audits and fewer disputes about billing and collection. That ultimately leads to a more convenient and comfortable procedure on both sides. If co-education is occurring between payers and providers about how each of these parties operates in relation to the entire billing process, then a lot of the inefficiency in our health care system today can be dramatically reduced. Going even further into real-time connectivity that essentially ‘pre-checks’ the claim submission for common errors, omissions or policy violations can eliminate those inefficiencies even further. I think a lot of it can be solved with greater upfront collaboration, incentive creation and understanding.
To learn more, read Optum’s whitepaper, “Data and the Shift to Risk” at www.optum.com/s2r