a payer’s perspective: business intelligence and analytics

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?