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A Payer’s Perspective: Business Intelligence and
Analytics
AmeriHealth Mercy
Overview• Started as Mercy Health Plan in early 1980’s• Managed care solutions for physical health, behavioral health, and
pharmacy services• Predominant focus is on Medicaid populations• Physical Health plans in 6 States, 2 more going live in 2012
Challenges• Limited funding• Characteristics of population
Underlying Goals of Payer Analytics
• Understand utilization and cost trends• Improve clinical outcomes• Prevent unnecessary services• Improve HEDIS scores• Maximize revenue• Influence policy• Align incentives• Identify trends early – appropriate interventions
Critical Functions
• Add value to existing data• Getting data into the right hands at the right time• Continually seek out new data sources
Key Data Domains
• Member• Provider• Claims – PH/BH/Rx• Care Management• Pharmacy• External Data Sources
Data Schematic
General Management
Management Dashboards
“Make Every Member Contact Count”
“360o View of the Member”
Member Data
• Demographics• Claims data (Medical, Dental, Vision) – including historical data• Pharmacy data• Race/Ethnicity/Language• Coverage Category• Lab Results• Risk Scores – prospective, concurrent• PCP History• Clinical Conditions• Maternity History• Etc….
Clinical Care Gaps
Early Intervention
Early Identification and Stratification of High Risk Maternity Cases
• Prenatal Vitamins• Lab Codes• Lab Test Results• Member Risk Score• Medication History• Diagnosis codes (e.g., SMI)• Age• Health Risk Assessment Reponses• Prior Delivery History
Patient Stratification Algorithms
Likelihood of Hospitalization
Risk Driver Conditions
Rank Age GenderLOH
ScoreDiabetes CAD COPD CHF Asthma
Decubitus Ulcer
Cardio-Respiratory
ArrestTotal
1 38 F 0.99 - - X - X - - 21 11 M 0.99 - - - - X - - 21 62 F 0.99 X X - - - - - 31 43 F 0.99 - - X X - - X 31 3 F 0.99 - - - - X - X 21 37 F 0.99 X X - X X - X 71 4 F 0.99 - - - - - - - 31 62 F 0.99 - - - - - - - 22 62 F 0.99 X X - - - - - 33 25 F 0.99 - - - - X - - 14 57 F 0.98 X - X X X - - 75 52 F 0.97 - - X X - - - 26 49 F 0.95 - - X - X - - 37 51 M 0.94 - X X - X - - 58 36 M 0.93 - - - - - - - 19 28 F 0.91 X - - - X - - 310 1 M 0.91 - - - - - - X 211 43 F 0.88 X - - X X - - 412 61 F 0.86 X X X - X - - 613 47 F 0.83 X X X X X - X 9
Align Incentives with Providers
Shared Savings: Potentially Preventable Readmits
PQI Reporting
Top 20 PCP Groups Drilldown
Admissions Between 1/2010 and 12/2010 Paid Through March 2011
PQI3 - Diabetes Long-term Complication Admission Rate
NO Group ID Group NameTotal Admits for Facility
Inclusion Admits*
Avoidable Admits Avoidable %
Paid Amount for Avoidable Admits
Average Cost/ Avoidable Admit
1 20008298 118 50 8 16.0% $56,662 $7,083
2 20003456 85 47 6 12.8% $147,113 $24,519
3 20000049 78 28 5 17.9% $78,667 $15,733
4 20015716 130 33 5 15.2% $37,270 $7,454
5 20050838 212 39 4 10.3% $29,752 $7,438
6 20004619 196 50 3 6.0% $35,211 $11,737
7 20004307 219 40 3 7.5% $17,372 $5,791
PCP Specific Statistics
Strategic Analytic ToolsToday:
Verisk Groupers
DxCG Risk Scoring
Likelihood of Hospitalization
Treo Services
MedAssurant – Catalyst
Internal Algorithms
Access Databases
Soon:
Sybase IQ
WEB Intelligence (WEBi)
User Maintained Production Schemas
Data Quality/Profiling
Looking Ahead
Future Directions:• Innovative algorithms• “Logical” phone queues• Infrastructure strategies• Reform implications• HIE• Social media
Innovative Member Algorithms
Ability to “Impact” Member• Success in contacting Member• Ratio of PCP to ER visits• Medication compliance• Rate of historical “preventable” events• Participation in prior programs• Overall family “compliance” score
Health Information Exchange
Thank You!!
Questions?