Category Archives: Healthcare
However, there is another wearable that has my attention – a wearable designed to save children’s lives: Embrace. Embrace is the first medical-quality wearable to help measure stress, epileptic seizures, activity and sleep. The idea is it an be used to detect early signs of an event and alert you when an unusual event is about to happen. If you have a toddler or infant, the wearable could alert parents in the middle of the night. As a mother of four children, peace of mind in the night is king.
Imagine the possibilities.
Biometric data collected from devices like these when used in the classroom could be used as a predictor children with Autism, Asperger Syndrome, or Mood Disorders to help clinicians, educators and parents better understand when a child is starting to become dis regulated. Integrating that data with therapeutic and educational strategies could potentially provide insight into a practice that is largely trial and error.
I pledged my support for Embrace in hopes that innovation in this field will continue to prosper, saving lives, and ultimately making a difference in the world.
At the DIA conference in Berlin this month, Frits Stulp of Mesa Arch Consulting suggested that IDMP could get the business asking for MDM. After looking at the requirements for IDMP compliance for approximately a year, his conclusion from a business point of view is that MDM has a key role to play in IDMP compliance. A recent press release by Andrew Marr, an IDMP and XEVMPD expert and specialist consultant, also shows support for MDM being ‘an advantageous thing to do’ for IDMP compliance. A previous blog outlined my thoughts on why MDM can turn regulatory compliance into an opportunity, instead of a cost. It seems that others are now seeing this opportunity too.
So why will IDMP enable the business (primarily regulatory affairs) to come to the conclusion that they need MDM? At its heart, IDMP is a pharmacovigilance initiative which has a goal to uniquely identify all medicines globally, and have rapid access to the details of the medicine’s attributes. If implemented in its ideal state, IDMP will deliver a single, accurate and trusted version of a medicinal product which can be used for multiple analytical and procedural purposes. This is exactly what MDM is designed to do.
Here is a summary of the key reasons why an MDM-based approach to IDMP is such a good fit.
1. IDMP is a data Consolidation effort; MDM enables data discovery & consolidation
- IDMP will probably need to populate between 150 to 300 attributes per medicine
- These attributes will be held in 10 to 13 systems, per product.
- MDM (especially with close coupling to Data Integration) can easily discover and collect this data.
2. IDMP requires cross-referencing; MDM has cross-referencing and cleansing as key process steps.
- Consolidating data from multiple systems normally means dealing with multiple identifiers per product.
- Different entities must be linked to each other to build relationships within the IDMP model.
- MDM allows for complex models catering for multiple identifiers and relationships between entities.
3. IDMP submissions must ensure the correct value of an attribute is submitted; MDM has strong capabilities to resolve different attribute values.
- Many attributes will exist in more than one of the 10 to 13 source systems
- Without strong data governance, these values can (and probably will be) different.
- MDM can set rules for determining the ‘golden source’ for each attribute, and then track the history of these values used for submission.
4. IDMP is a translation effort; MDM is designed to translate
- Submission will need to be within a defined vocabulary or set of reference data
- Different regulators may opt for different vocabularies, in addition to the internal set of reference data.
- MDM can hold multiple values/vocabularies for entities, depending on context.
5. IDMP is a large co-ordination effort; MDM enables governance and is generally associated with higher data consistency and quality throughout an organisation.
- The IDMP scope is broad, so attributes required by IDMP may also be required for compliance to other regulations.
- Accurate compliance needs tracking and distribution of attribute values. Attribute values submitted for IDMP, other regulations, and supporting internal business should be the same.
- Not only is MDM designed to collect and cleanse data, it is equally comfortable for data dispersion and co-ordination of values across systems.
Once business users assess the data management requirements, and consider the breadth of the IDMP scope, it is no surprise that some of them could be asking for a MDM solution. Even if they do not use the acronym ‘MDM’ they could actually be asking for MDM by capabilities rather than name.
Given the good technical fit of a MDM approach to IDMP compliance, I would like to put forward three arguments as to why the approach makes sense. There may be others, but these are the ones I feel are most compelling:
1. Better chance to meet tight submission time
There is slightly over 18 months left before the EMA requires IDMP compliance. Waiting for final guidance will not provide enough time for compliance. Using MDM you have a tool to begin with the most time consuming tasks: data discovery, collection and consolidation. Required XEVMPD data, and the draft guidance can serve as a guide as to where to focus your efforts.
2. Reduce Risk of non-compliance
With fines in Europe of ‘fines up to 5% of revenue’ at stake, risking non-compliance could be expensive. Not only will MDM increase your chance of compliance on July 1, 2016, but will give you a tool to manage your data to ensure ongoing compliance in terms of meeting deadlines for delivering new data, and data changes.
3. Your company will have a ready source of clean, multi-purpose product data
Unlike some Regulatory Information Management tools, MDM is not a single-purpose tool. It is specifically designed to provide consolidated, high-quality master data to multiple systems and business processes. This data source could be used to deliver high-quality data to multiple other initiatives, in particular compliance to other regulations, and projects addressing topics such as Traceability, Health Economics & Outcomes, Continuous Process Verification, Inventory Reduction.
So back to the original question – will the introduction of IDMP regulation in Europe result in the business asking IT to implement MDM? Perhaps they will, but not by name. It is still possible that they won’t. However, for those of you who have been struggling to get buy-in to MDM within your organisation, and you need to comply to IDMP, then you may be able to find some more allies (potentially with an approved budget) to support you in your MDM efforts.
CMS points out the overall improvement in quality which they position as the result of focusing, and incenting quality. I agree that putting funding behind a quality program was a valuable strategy to motivate the industry. This has not always been the case, in fact a former colleague who related a common dialog previous to this program:
- He would present a quality initiative to executive management
- They would nod politely and say, “Yes, of course we are interested in quality!”
- The conversation would continue until the cost of the program was disclosed.
The faces would change, and the response was, “Well, yes, quality is important, but funding is tight right now. We need to focus on programs with a clear ROI”.
Thankfully the Star program has given quality initiatives a clear ROI – for which we are all grateful!
The other dynamic which is positive is that Medicare Advantage has provided a testing ground for new programs, largely the result of ACA. Programs very similar to the Star program are part of the ACO program and the marketplace membership. Risk Adjustment is being fitted to meet these programs also. Private insurance will likely borrow similar structures to insure quality and fair compensation in their various risk sharing arrangements. MA is a significant subset of the population and is providing an excellent sandbox for these initiatives while improving the quality of care that our senior population receives.
My concerns are around the cultures and mission of those plans who are struggling to get to the magic four star level where they will receive the bonus dollars.
Having worked in a health plan for almost nine years, and continuing to interact with my current customers, has shown me the dedication of the staffs that work in these plans. One of my most rewarding experiences was leading the call center for the Medicare population. I was humbled each day by the caring and patience the reps on the phones showed to the senior population. I have also seen the dedication of clinical staffs to insuring the care for members is carefully coordinated and that their dignity and wishes were always respected. I sincerely hope that plans with a clear mission find the right tools and supports to improve their ratings to the point where they receive the additional funding to maintain their viability and continue to serve their members and the medical community. I am sure that there are poor quality plans out there, and I agree that they should be eliminated. But I am also rooting for the plans with a mission who are striving to be a bit better.
What is our personal information worth?
With this 2014 holiday season rolling into full swing, Americans will spend more than $600 Billion, a 4.1% increase from last year. According to the Credit Union National Association, a poll showed that 45% of credit and debit card users will think twice about how they shop and pay given the tens of millions of shoppers impacted by breaches. Stealing identities is a lucrative pastime for those with ulterior motives. The Black Market pays between $10-$12 per stolen record. Yet when enriched with health data, the value is as high as $50 per record because it can be used for insurance fraud.
Are the thieves getting smarter or are we getting sloppy?
With ubiquitous access to technology globally, general acceptance to online shopping, and the digitization of health records, there is more data online with more opportunities to steal our data than ever before. Unfortunately for shoppers, 2013 was known as ‘the year of the retailer breach’ according to the Verizon’s 2014 data breach report. Unfortunately for patients, Healthcare providers were most noted for the highest percentage of losing protected healthcare data.
So what can we do to be a smarter and safer consumer?
No one wants to bank roll the thieves’ illegal habits. One way would be to regress 20 years, drive to the mall and make our purchases cash in hand or go back to completely paper-based healthcare. Alternatively, here are a few suggestions to avoid being on the next list of victims:
1. Avoid irresponsible vendors and providers by being an educated consumer
Sites like The Identify Theft Resource Center and the US Department of Health and Human Services expose the latest breaches in retail and healthcare respectively. Look up who you are buying from and receiving care from and make sure they are doing everything they can to protect your data. If they didn’t respond in a timely fashion, tried to hide the breach, or didn’t implement new controls to protect your data, avoid them. Or take your chances.
2. Expect to be hacked, plan for it
Most organizations you trust with your personal information have already experienced a breach. In fact, according to a recent survey conducted by the Ponemon Group sponsored by Informatica, 72% of organizations polled experienced a breach within the past 12 months; more than 20% had 2 or more breaches in the same timeframe. When setting passwords, avoid using words or phrases that you publicly share on Facebook. When answering security questions, most security professionals suggest that you lie!
3. If it really bothers you, be vocal and engage
Many states are invoking legislation to make organizations accountable for notifying individuals when a breach occurs. For example, Florida enacted FIPA – the Florida Information Protection Act – on July 1, 2014 that stipulates that all breaches, large or small, are subject to notification. For every day that a breach goes undocumented, FIPA stipulates $1,000 per day penalty up to an annual limit of $500,000.
In conclusion, as the holiday shopping season approaches, now is the perfect time for you to ensure that you’re making the best – and most informed – purchasing decisions. You have the ability to take matters into your own hands; keep your data secure this year and every year.
To learn more about Informatica Data Security products, visit our Data Privacy solutions website.
The Rising CFO is Increasingly Business Oriented
At the CFO Rising West Conference on October 30th and 31st, there were sessions on managing capital expenditures, completing an IPO, and even managing margin and cash flow. However, the keynote presenters did not spend much of time on these topics. Instead, they focused on how CFOs need to help their firms execute better. Here is a quick summary of the suggestions made from CFOs in broadcasting, consumer goods, retail, healthcare, and medical devices.
The Modern CFO is Strategic
The Broadcasting CFO started his talk by saying he was not at the conference to share why CFOs need to move from being “bean counters to strategic advisors”. He said “let’s face it the modern CFO is a strategic CFO”. Agreeing with this viewpoint, the Consumer Goods CFO said that finance organizations have a major role to play in business transformation. He said that finance after all is the place to drive corporate improvement as well as business productivity and business efficiency.
CFOs Talked About Their Business’ Issues
The Retailer CFO talked like he was a marketing person. He said retail today is all about driving a multichannel customer experience. To do this, finance increasingly needs to provide real business value. He said, therefore, that data is critical to the retailer’s ability to serve customers better. He claimed that customers are changing how they buy, what they want to buy, and when they want to buy. We are being disrupted and it is better to understand and respond to these trends. We are trying, therefore, to build a better model of ecommerce.
Meanwhile, the Medical Devices CFO said that as a supplier to medical device vendors “what we do is compete with our customers engineering staffs”. And the Consumer Goods CFO added the importance of finance driving sustained business transformation.
CFOs Want To Improve Their Business’ Ability To Execute
The Medical Devices CFO said CFOs need to look for “earlier execution points”. They need to look for the drivers of behavior change. As a key element of this, he suggested that CFOs need to develop “early warning indicators”. He said CFOs need to actively look at the ability to achieve objectives. With sales, we need to ask what deals do we have in the pipe? At what size are these deals? And at what success rate will these deals be closed? Only with this information, can the CFO derive an expected company growth rate. He then asked CFOs in the room to identify themselves. With their hands in the air, he asked them are they helping to create a company that executes or not. He laid down the gauntlet for the CFOs in the room by then asserting that if you are not creating a company that executes then are going to be looking at cutting costs sooner rather than later.
The retailer CFO agreed with this CFO. He said today we need to focus on how to win a market. We need to be asking business questions including:
- How should we deploy resources to deliver against our firm’s value proposition?
- How do we know when we win?
CFOs Claim Ownership For Enterprise Performance Measurement
The Retail CFO said that finance needs to own “the facts for the organization”—the metrics and KPIs. This is how he claims CFOs will earn their seat at the CEOs table. He said in the past the CFO have tended to be stoic, but this now needs to change.
The Medical Devices CFO agreed and said enterprises shouldn’t be tracking 150 things—they need to pare it down to 12-15 things. They need to answer with what you measure—who, what, and when. He said in an execution culture people need to know the targets. They need measurable goals. And he asserted that business metrics are needed over financial metrics. The Consumer Goods CFO agreed by saying financial measures alone would find that “a house is on fire after half the house had already burned down”. The Healthcare CFO picked up on this idea and talked about the importance of finance driving value scorecards and monthly benchmarks of performance improvement. The broadcaster CFO went further and suggested the CFO’s role is one of a value optimizer.
CFOs Own The Data and Drive a Fact-based, Strategic Company Culture
The Retail CFOs discussed the need to drive a culture of insight. This means that data absolutely matters to the CFO. Now, he honestly admits that finance organizations have not used data well enough but he claims finance needs to make the time to truly become data centric. He said I do not consider myself a data expert, but finance needs to own “enterprise data and the integrity of this data”. He said as well that finance needs to ensure there are no data silos. He summarized by saying finance needs to use data to make sure that resources are focused on the right things; decisions are based on facts; and metrics are simple and understandable. “In finance, we need use data to increasingly drive business outcomes”.
CFOs Need to Drive a Culture That Executes for Today and the Future
Honestly, I never thought that I would hear this from a group of CFOs. The Retail CFO said we need to ensure that the big ideas do not get lost. We need to speed-up the prosecuting of business activities. We need to drive more exponential things (this means we need to position our assets and resources) and we need, at the same time, to drive the linear things which can drive a 1% improvement in execution or a 1% reduction in cost. Meanwhile, our Medical Device CFO discussed the present value, for example, of a liability for rework, lawsuits, and warranty costs. He said that finance leaders need to ensure things are done right today so the business doesn’t have problems a year from today. “If you give doing it right the first time a priority, you can reduce warranty reserve and this can directly impact corporate operating income”.
CFOs need to lead on ethics and compliance
The Medical Devices CFO said that CFOs, also, need to have high ethics and drive compliance. The Retail CFO discussed how finance needs to make the business transparent. Finance needs to be transparent about what is working and what is not working. The role of the CFO, at the same time, needs to ensure the integrity of the organization. The Broadcaster CFO asserted the same thing by saying that CFOs need to take a stakeholder approach to how they do business.
In whole, CFOs at CFO Rising are showing the way forward for the modern CFOs. This CFO is all about the data to drive present and future performance, ethics and compliance, and business transparency. This is a big change from the historical controller approach and mentality. I once asked a boss about what I needed to be promoted to a Vice President; my boss said that I needed to move from a technical specialist to a business person. Today’s CFOs clearly show that they are a business person first.
Solution Brief: The Intelligent Data Platform
CFOs Move to Chief Profitability Officer
CFOs Discuss Their Technology Priorities
The CFO Viewpoint upon Data
How CFOs can change the conversation with their CIO?
New type of CFO represents a potent CIO ally
Competing on Analytics
The Business Case for Better Data Connectivity
Saeed, what does Decision Point do?
We are a healthcare engagement analytics company…essentially we help clients that are “at risk” organizations to improve performance, including STAR ratings. We do this by providing data driven insights to more effectively engage members and providers.
What type of data do you use to make these recommendations?
Well, taking better care of members is about emotionally involving them in their care. Information to help do this resides in data that plans already have available, i.e. utilization patterns, distance to doctors, if they are compliant with evidence based guidelines, do they call into the call center. We also seek to include information about their behavior as a consumer. such as their lifestyles, their access to technology, and so forth.
Claims data makes sense, everyone has that but the other data you mentioned, that can be harder to capture. Why does non-claims oriented data matter?
We develop predictive models that are unique for each client – specifically based on the demographics and variables of their population. Variables like exercise and technology access matter because — for example, exercise habits influence mood and access to technology demonstrates a way to contact them or invite them to participate in online communities with other members like themselves.
The predictive models then determine which members are at most risk?
Yes, yes they do but they can also determine a member’s barriers to desired behavior, and their likelihood of responding to and acting on health plan communications. For example, if we identified a diabetic member as high risk of non-compliance, found their primary barrier to compliance as health literacy, and determined that the member will likely respond positively to a combination of health coaching and mobile health initiatives, we would recommend outreach that directly addresses these findings..
Noreen, when you were working on the payer side of the house, how were you going about determining which members were in your at risk population?
We had teams of people doing mining of claims data and we were asking members to complete surveys. This made for more data but the sheer volume of data made it complex to accurately review and assess which members were at highest risk. It was very challenging to take into consideration all of the variables that impact each member. Taking data from so many disparate sources and bringing it together is a big challenge.
What made it (and continues to make it) it so challenging, specifically to STARS?
So much of the data is collected as surveys or in other non-standard formats. Members inherently are unique which creates a lot of variability and it is often difficult to interpret the relationships that exist between members and primary care physicians, specialists, facilities and the rest of their care team. Relationships are important because they can provide insights into utilization patterns, potential overlaps or gaps in care and how we can most effectively engage those members in their care.
What are Informatica and Decision Point doing together?
To optimize the predictive models, as Saeed described, it’s imperative to feed them as much data and as accurate of data as possible. Without data, insights will be missed… and insights are the path to discovery and to improving CMS STARS ratings. Informatica is the data integration company — we ensure that data is reliable), connected (from any source to any target) and safe (avoiding data breaches or HIPAA violations). Informatica is delivering data to Decision Point efficiently and effectively so that clients have access to the best data possible to derive insights and improve outcomes. Our technology also provided the Star team with a member profile which brings together that disparate data and organizes it into the 360 degree view of that member. In addition to fueling Decision Point’s powerful algorithms, this is a tool that can be used for ongoing insights into the members.
Excellent, how can readers learn more?
In my last blog, I talked about the dreadful experience of cleaning raw data by hand as a former analyst a few years back. Well, the truth is, I was not alone. At a recent data mining Meetup event in San Francisco bay area, I asked a few analysts: “How much time do you spend on cleaning your data at work?” “More than 80% of my time” and “most my days” said the analysts, and “they are not fun”.
But check this out: There are over a dozen Meetup groups focused on data science and data mining here in the bay area I live. Those groups put on events multiple times a month, with topics often around hot, emerging technologies such as machine learning, graph analysis, real-time analytics, new algorithm on analyzing social media data, and of course, anything Big Data. Cools BI tools, new programming models and algorithms for better analysis are a big draw to data practitioners these days.
That got me thinking… if what analysts said to me is true, i.e., they spent 80% of their time on data prepping and 1/4 of that time analyzing the data and visualizing the results, which BTW, “is actually fun”, quoting a data analyst, then why are they drawn to the events focused on discussing the tools that can only help them 20% of the time? Why wouldn’t they want to explore technologies that can help address the dreadful 80% of the data scrubbing task they complain about?
Having been there myself, I thought perhaps a little self-reflection would help answer the question.
As a student of math, I love data and am fascinated about good stories I can discover from them. My two-year math program in graduate school was primarily focused on learning how to build fabulous math models to simulate the real events, and use those formula to predict the future, or look for meaningful patterns.
I used BI and statistical analysis tools while at school, and continued to use them at work after I graduated. Those software were great in that they helped me get to the results and see what’s in my data, and I can develop conclusions and make recommendations based on those insights for my clients. Without BI and visualization tools, I would not have delivered any results.
That was fun and glamorous part of my job as an analyst, but when I was not creating nice charts and presentations to tell the stories in my data, I was spending time, great amount of time, sometimes up to the wee hours cleaning and verifying my data, I was convinced that was part of my job and I just had to suck it up.
It was only a few months ago that I stumbled upon data quality software – it happened when I joined Informatica. At first I thought they were talking to the wrong person when they started pitching me data quality solutions.
Turns out, the concept of data quality automation is a highly relevant and extremely intuitive subject to me, and for anyone who is dealing with data on the regular basis. Data quality software offers an automated process for data cleansing and is much faster and delivers more accurate results than manual process. To put that in math context, if a data quality tool can reduce the data cleansing effort from 80% to 40% (btw, this is hardly a random number, some of our customers have reported much better results), that means analysts can now free up 40% of their time from scrubbing data, and use that times to do the things they like – playing with data in BI tools, building new models or running more scenarios, producing different views of the data and discovering things they may not be able to before, and do all of that with clean, trusted data. No more bored to death experience, what they are left with are improved productivity, more accurate and consistent results, compelling stories about data, and most important, they can focus on doing the things they like! Not too shabby right?
I am excited about trying out the data quality tools we have here at Informtica, my fellow analysts, you should start looking into them also. And I will check back in soon with more stories to share..
Regardless of the industry, new regulatory compliance requirements are more often than not treated like the introduction of a new tax. A few may be supportive, some will see the benefits, but most will focus on the negatives – the cost, the effort, the intrusion into private matters. There will more than likely be a lot of grumbling.
Across many industries there is currently a lot of grumbling, as new regulation seems to be springing up all over the place. Pharmaceutical companies have to deal with IDMP in Europe and UDI in the USA. This is hot on the heels of the US Sunshine Act, which is being followed in Europe by Aggregate Spend requirements. Consumer Goods companies in Europe are looking at the consequences of beefed up 1169 requirements. Financial Institutes are mulling over compliance to BCBS-239. Behind the grumbling most organisations across all verticals appear to have a similar approach to regulatory compliance. The pattern seems to go like this:
- Delay (The requirements may change)
- Scramble (They want it when? Why didn’t we get more time?)
- Code to Spec (Provide exactly what they want, and only what they want)
No wonder these requirements are seen as purely a cost and an annoyance. But it doesn’t have to be that way, and in fact, it should not. Just like I have seen a pattern in response to compliance, I see a pattern in the requirements themselves:
- The regulators want data
- Their requirements will change
- When they do change, regulators will be wanting even more data!
Now read the last 3 bullet points again, but use ‘executives’ or ‘management’ or ‘the business people’ instead of ‘regulators’. The pattern still holds true. The irony is that execs will quickly sign off on budget to meet regulatory requirements, but find it hard to see the value in “infrastructure” projects. Projects that will deliver this same data to their internal teams.
This is where the opportunity comes in. pwc’s 2013 State of Compliance Report[i] shows that over 42% of central compliance budgets are in excess of $1m. A significant figure. Efforts outside of the compliance team imply a higher actual cost. Large budgets are not surprising in multi-national companies, who often have to satisfy multiple regulators in a number of countries. As an alternate to multiple over-lapping compliance projects, what if this significant budget was repurposed to create a flexible data management platform? This approach could deliver compliance, but provide even more value internally.
Almost all internal teams are currently clamouring for additional data to drive ther newest application. Pharma and CG sales & marketing teams would love ready access to detailed product information. So would consumer and patient support staff, as well as down-stream partners. Trading desks and client managers within Financial Institutes should really have real-time access to their risk profiles guiding daily decision making. These data needs will not be going away. Why should regulators be prioritised over the people who drive your bottom line and who are guardians of your brand?
A flexible data management platform will serve everyone equally. Foundational tools for a flexible data management platform exist today including Data Quality, MDM, PIM and VIBE, Informatica’s Virtual Data Machine. Each of them play a significant role in easing of regulatory compliance, and as a bonus they deliver measureable business value in their own right. Implemented correctly, you will get enhanced data agility & visibility across the entire organisation as part of your compliance efforts. Sounds like ‘Buy one Get One Free’, or BOGOF in retail terms.
Unlike taxes, BOGOF opportunities are normally embraced with open arms. Regulatory compliance should receive a similar welcome – an opportunity to build the foundations for universal delivery of data which is safe, clean and connected. A 2011 study by The Economist found that effective regulatory compliance benefits businesses across a wide range of performance metrics[ii].
Is it time to get your free performance boost?
Before I joined Informatica I worked for a health plan in Boston. I managed several programs including CMS Five Start Quality Rating System and Risk Adjustment Redesign. We recognized the need for a robust diagnostic profile of our members in support of risk adjustment. However, because the information resides in multiple sources, gathering and connecting the data presented many challenges. I see the opportunity for health plans to transform risk adjustment.
As risk adjustment becomes an integral component in healthcare, I encourage health plans to create a core competency around the development of diagnostic profiles. This should be the case for health plans and ACO’s. This profile is the source of reimbursement for an individual. This profile is also the basis for clinical care management. Augmented with social and demographic data, the profile can create a roadmap for successfully engaging each member.
Why is risk adjustment important?
Risk Adjustment is increasingly entrenched in the healthcare ecosystem. Originating in Medicare Advantage, it is now applicable to other areas. Risk adjustment is mission critical to protect financial viability and identify a clinical baseline for members.
What are a few examples of the increasing importance of risk adjustment?
1) Centers for Medicare and Medicaid (CMS) continues to increase the focus on Risk Adjustment. They are evaluating the value provided to the Federal government and beneficiaries. CMS has questioned the efficacy of home assessments and challenged health plans to provide a value statement beyond the harvesting of diagnoses codes which result solely in revenue enhancement. Illustrating additional value has been a challenge. Integrating data across the health plan will help address this challenge and derive value.
2) Marketplace members will also require risk adjustment calculations. After the first three years, the three “R’s” will dwindle down to one ‘R”. When Reinsurance and Risk Corridors end, we will be left with Risk Adjustment. To succeed with this new population, health plans need a clear strategy to obtain, analyze and process data. CMS processing delays make risk adjustment even more difficult. A Health Plan’s ability to manage this information will be critical to success.
3) Dual Eligibles, Medicaid members and ACO’s also rely on risk management for profitability and improved quality.
With an enhanced diagnostic profile — one that is accurate, complete and shared — I believe it is possible to enhance care, deliver appropriate reimbursements and provide coordinated care.
How can payers better enable risk adjustment?
- Facilitate timely analysis of accurate data from a variety of sources, in any format.
- Integrate and reconcile data from initial receipt through adjudication and submission.
- Deliver clean and normalized data to business users.
- Provide an aggregated view of master data about members, providers and the relationships between them to reveal insights and enable a differentiated level of service.
- Apply natural language processing to capture insights otherwise trapped in text based notes.
With clean, safe and connected data, health plans can profile members and identify undocumented diagnoses. With this data, health plans will also be able to create reports identifying providers who would benefit from additional training and support (about coding accuracy and completeness).
What will clean, safe and connected data allow?
- Allow risk adjustment to become a core competency and source of differentiation. Revenue impacts are expanding to lines of business representing larger and increasingly complex populations.
- Educate, motivate and engage providers with accurate reporting. Obtaining and acting on diagnostic data is best done when the member/patient is meeting with the caregiver. Clear and trusted feedback to physicians will contribute to a strong partnership.
- Improve patient care, reduce medical cost, increase quality ratings and engage members.