On the Road to ACO: How Hospitals Can Mine Nuggets from Mountains of Claims Data

For the accountable care model to achieve its potential and purpose, hospitals need visibility beyond their walls to understand where and when patients are seeking health services, and how that access ultimately affects the bottom-line. However, many hospital executives would admit that that their organization’s road to accountable care has been bumpy rather than uplifting.

Welcome to Pioneer Country

Predictably, these executives are being criticized for over-promising and under-delivering. However, it is not fair to lay the blame at the feet of hospital leadership. They make an easy target and hindsight is 20/20. But to criticize executives for failing to read and follow the ACO instruction manual is invalid. Frankly, there is no instruction manual. For that matter, there is also no GPS, map, trail, marker stones, tea leaves, or astrological charts for guidance. As such, in most cases executives should be appreciated rather than attacked for doing the best they can to try moving the ball down the field; or at least, stay in the game. This is new territory for everyone. We are in pioneer country.

However, if we remember from history class — or maybe just watching some Gilligan’s Island — being a pioneer is not all about battling the weather and fending off wild beasts. Necessity is the mother of invention, it has given birth to one of the most important and insightful discoveries in the ACO era: unsexy, unheralded claims data — by far the most ubiquitous of all healthcare data — is a surprisingly large part of the solution.

“Claims data generates visibility into the full spectrum of care delivery as attributed patients move from provider to provider, and from system to system.”

The Glory of Claims Data

This is because claims data — and for the moment, only claims data — generates visibility into the full spectrum of care delivery as attributed patients move from provider to provider, and from system to system. In a perfect world these systems would all speak the same language, meet the same security and compliance standards, and sync in real-time. But we are not there yet; in fact, we are not even close! As such, claims data is the common denominator that tells providers what their patients are doing, when and with whom. This information is essential to understanding both patient heath and wellness, and a hospital’s financial health and wellness.

And yet despite its value, many hospitals are not using claims data in this way. For example, imagine an employee who must contact 1,000 primary care providers each quarter to ensure that they know about various wellness visits (e.g. mammograms, diabetic eye exams, colonoscopies, etc.) performed at other locations. This is a massively time consuming administrative burden — and frankly, a real tedious grind — but there is no other option, because those 1,000 primary care providers are outside the hospital’s system. Alas, the beleaguered employee, perhaps with a small team, is responsible for connecting the dots to make a comprehensible picture — one phone call at a time.

A Better Way

Thankfully, there is a better way. The same employee can log into a dashboard, and generate customized reports that are automatically populated by claims data from inside and outside the system. Instead of making thousands of calls a year, she simply needs to distribute the reports. It is a profoundly better approach, and all by supplementing rather than replacing what the hospital is already doing.

In addition, claims data can also play a key role in helping measure the efficacy of post acute care. For example, after discharging patients to skilled nursing facilities and/or home health providers, hospitals can use claims data to generate more transparency into the level of care and involvement that these providers are giving to their patients (e.g. monitor home health visits and durations). Hospitals can then merge claims data with their own data to gain insights into the continuum of care (e.g. readmission rates, ED Visits, LOS, etc.). To sharpen the focus, they can also further segment patients into diseases, geographies, and other categories.

The Golden Key?

With this in mind, is claims data the golden key that unlocks the potential and purpose of accountable care? No, it isn’t. There are limitations, including that the data only applies to patients 65 years and older (although some hospitals are getting Medicaid data). In addition, each organization uses a different format for their claims data, and they are constantly changing eligibility format (i.e. knowing who is covered is a different process for each payor). This is a massively time consuming and potentially error-prone manual task without automation.

Granted, these are notable — and frankly, messy — drawbacks that will hopefully diminish over time. However, despite these challenges, hospitals can and should leverage automation to mine the nuggets from the mountains of claims at their disposal. By doing so, they move closer to representing what accountable care is essentially all about: ensuring that that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical error. When that happens, there are no losers. Only winners.

Learn More

At Polaris, we help hospitals mine nuggets from mountains of claims data, in order to ensure that vital information is always current, accurate and available — and the organization gets smarter as it grows.

To learn more about our solutions, technologies and approach contact Polaris today.

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