Posts Tagged ‘health risk stratification’

Guest Post: Lab Data is the Missing Link in Healthcare Risk Adjustment

June 19th, 2018 by Jason Bhan, MD

Data informing risk adjustment programs is critical under value-based healthcare reimbursement models.

For health plans, value-based care means a continuous need to innovate and improve their risk adjustment, clinical quality, and care management programs. Unless payers identify and receive the correct amount of reimbursement, it is difficult for them to invest appropriately into member care programs for better outcomes while remaining financially successful.

The data informing risk adjustment programs are critical, as they build the foundation for accurate member risk stratification. In that respect, those data sources are directly related to the correct amount of reimbursement payers receive and can invest in proactive care management. In other words, high-quality clinical data delivered quickly enough for a plan to get a member into a care management program early enough is important to the health of the member and the business. The approach leads to improved clinical outcomes and reduced costs in emergency room visits, hospitalizations and chronic condition management.

Lab Data: An Untapped Resource

To achieve such clinical granularity, at scale, plans can turn to diagnostics—or lab—data. Lab data drives approximately 70 percent of medical decisions and, unlike claims data, is available in near real-time. It also provides an unrivaled level of specificity for clinical conditions. When lab data is integrated into plans’ claims- and chart-based programs, it enables earlier, more comprehensive and accurate clinical insights to benefit care management of both existing and new members. Utilizing the same information that clinicians use to make decisions, within the same timeframe, provides a powerful and unique opportunity to intervene and impact a patient’s health.

What Can Lab Data Do for You?

Expanding and improving their clinical data supply with diagnostics data can help health plans to:

  • Provide historical insights on members where claims are unavailable to improve risk adjustment. For new enrollees, this enables the health plan to get new members into the appropriate care/disease management programs from day one.
  • Serve as an early detection system for care management of all enrollees. Plans can identify patients in need of additional or alternative therapy from lab data earlier than from any other data source. For existing members, the detailed results uncover needs that may have been overlooked based on a claims analysis alone.
  • Identify high-risk members for case management and provider interventions from lab data. Optimized risk adjustment aligns reimbursements to health status, enabling the plan to more heavily invest in member care programs.

Applying AI Solutions

When it comes to gaining actionable insights from diagnostics data, plans can benefit from partnering with healthcare artificial intelligence (AI) specialists in the field. Healthcare AI organizations use techniques such as machine learning and natural language processing—coupled with massive computational power—on big data sets, to make sense out of non-standard, complex, and heterogeneous data.

Healthcare AI, when applied to diagnostics clinical lab data, improves risk stratification by identifying diagnoses earlier in the year versus waiting for the claim or searching charts. Rich in clinical details, it presents a more complete picture of the member’s health. Better risk stratification leads to better care management programs; and successful programs have been shown to reduce costs by targeting those most likely to benefit and keeping intervention costs low.

Dr. Jason Bhan

About the Author: Jason Bhan, MD, is co-founder and Chief Medical Officer at Prognos, an innovator in applying AI to clinical lab diagnostics. More than half of the Prognos team is made of engineers, data scientists, and clinicians. Prognos aims to increase the usefulness of disparate healthcare data to better inform clinical decisions and ultimately improve patient outcomes.

Infographic: The Impact of Social Determinants on Health

July 6th, 2016 by Melanie Matthews

A range of personal, social, economic and environmental factors contribute to individual and population health, according to a new infographic by Healthy People 2020.

The infographic examines high school graduation rates by ethnicity/race and the impact of a quality education on health.

When success in a fee-for-value reimbursement framework calls for a care coordination vision focused on the highest-risk, highest-cost patients, an organization must be able to identify this critical population.

2016 Healthcare Benchmarks: Stratifying High-Risk Patients captures the latest tools and practices employed by healthcare organizations across the care continuum as they risk-stratify patients and health plan members in preparation for care management.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Home Visits Offer ‘Eyes on the Ground’ for High-Risk Populations

October 31st, 2013 by Patricia Donovan

Despite the explosion of mobile and telehealth technologies, there’s no substitute for person-to-person contact — at least when it comes to populations at high risk of hospital admission or readmission.

That was the finding of our inaugural Home Visits study, which captured the use of health-related home visits by 155 healthcare organizations. Almost 80 percent of respondents to the August 2013 survey visit some percentage of their patients or health plan members in their homes, a practice that is dramatically increasing levels of medication adherence and patient satisfaction.

Charged with keeping costly readmissions penalties at bay, healthcare organizations are deploying healthcare workers to the homes of risk-stratified patients and health plan members in greater numbers. While the primary purpose of the visit may vary by sector (payors’ case managers performing a home assessment versus hospitals clarifying discharge instructions), the end result is keeping patients safer and healthier in their homes and curbing costlier utilizers.

The home visit may also be the time to initiate the serious conversations — the ones that address end-of-life care and support, so that individuals have more control over the healthcare services they utilize during this final stage of the care continuum. These sensitive discussions can take place in the more relaxed setting of the patient’s home rather than at the hospital bedside.

What seems likely is that home visits will continue to proliferate, and supporting the home health workers, case managers, physicians and even pharmacists who conduct these visits will be portable technologies like a common electronic health record that all care providers can access, and telehealth tools such as interactive voice response (IVR) or disease-specific devices to transmit key health metrics (A1Cs or weight, for example) to the patient’s medical home.

Of course, the data tracked by these technologies must be shared among all providers so that coordination of care is seamless and duplication of care is avoided.

Scheduled telephonic follow-up should supplement more sophisticated technologies, survey respondents emphasized.

Download an executive summary of results from the 2013 Home Visits survey.