Download Thurs_1150am_PotomacAB_Business_ Claims Data How to

Determining Why Patients are Hospitalized via “Chart Review”
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The “Full Picture”
Claims can provide a succinct summary of care,
particularly across transitions in care
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Honing In
Using claims + clinical judgement à “why” a
patient was hospitalized often becomes
apparent
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Keeping Track of Overall Practice Performance in OCM
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The “Big Picture”
View
Keeping track of where your organization is as a
whole in OCM & where improvement in
physician engagement is needed
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Assessing Individual Physician Performan & How to Support
Improvement
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Looking at Top
Level Costs by
Physician &
Cancer
Physician x cancer level analyses helps create
hypotheses for care management interventions
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Utilization Rates
by Physician &
Cancer
Utilization vs cost à additional granularity in
developing programs & interventions
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Oncology is Different: Direct from Clinic /Physician
Scheduled Admissions
Care management requirements in oncology differ from other bundle payment models due to the severity of illness. Patients are
admitted from clinic/by physician often. Medicare claims data can be organized & modeled to reflect this
Hospital Admissions
Through ED
Observation
Transfer
Scheduled
Ambulance
Hospital
Walk in
Non-acute
facility e.g. SNF
Same Day Clinic Admits
Planned Physician Admits
Elective Procedure Admits
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Care Coordination
Functions vary by
Source of
Admission
Shaping care coordination to reduce admissions
in more targeted ways. Care coordination is
really multiple different “programs”
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Physician Score
Cards
Can be Effective Tools to Change Practice
Patterns
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Prioritizing Which Patients to Focus Your Care Coordinators Work On
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Segmenting the
Population
Way to prioritize staff & resources
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What’s the
”Right” Cohort
for Care
Coordination?
• Rates vs absolute totals
• Different pictures of utilization
• Different types of care coordintion functions
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What Happens
During a
Hospitalization?
ICU Utilization is critical to track in oncology
utilization
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ICU Care Utilization is a Major Issue in Oncology
Examining ICU utilization and variations in utilization is critical to setting up OCM programs
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Examining Pharmaceutical Utilization By Class of Agent
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Mapping
Individual Agents
to Class of Drug
Examining utilization of newer classes of agents
such as PD1/PDL1 inhibitors
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Understanding
Classes of Agents
as they Grow in
Size
Multiple agents mapping to a class of agent
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Drilling Down to
Individual Agents
from the Class
Variation in utilization of different agents from a
single class
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Assessing the Impact of Your Practice Transformation Interventions Tracking Changes in Performance Over Time
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Understanding
Trend
• Global view of how performance is evolving
• Break down into sub-groups
• Mapping interventions
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Tracking Episodes Over Their Life Cycle
OCM enrollment à rolling windw. Claims run out > 12 months
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Assessing Transitions in Care
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Looking Across
Settings of Care
• Claims provides strong insights on how
patients move between settings of care e.g.
hospital à post acute setting
• Help guide internal care management
protocols & policies e.g. all patients seen in
clinic 48 hours after discharge, etc
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Individual
Physicians Access
to Care
How physicians are scheduled has a major
impact on continuity of care & capacity for
integrated management
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Understanding Co-Morbidities to Manage Total Cost of Care
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Tracking CoMorbidities To
Manage Total
Cost
• Co-morbidities can require different
types of care coordination
• Cancer + co-morbidity can have
particular interactions
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Patient Sharing Network Analysis -Understanding Care Outside Your
Practice’s Wall
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Looking Inside &
Outside Your
Practice
• Gaining insight into who else is touching the
patient
• Basis for thinking about “referral
management"
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Measuring Impact of Innappropriate Variations in Care
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Organizing CMS Claims Data Using Clinical Knowledge to
Make it More Actionable
One Way of Looking at the Cost of Radiation Oncology
OCM Performance Feedback Report – Standard Way Radiation Therapy is Analyzed
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Organizing CMS Claims Data Using Clinical Knowledge to
Make it More Actionable
Getting to the cause of avoidable costs
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Thank you.