The Big Data Dividend

Transcription

1 The Big Data Dividend Enhancing Revenue in an Era of Change May 7, 2015

2 Agenda Big Data Sample Healthcare Big Data Sets Healthcare Applications of Big Data Revenue Enhancement Opportunities Rate Benchmarking/Rate Parity Analytics Strategic Pricing/Pricing Transparency Value Based (at-risk) Contracting Total Cost of Care Analytics Volume/ Leakage Analytics Key Infrastructure Needs 1

3 Big Data Any collection of datasets so large or complex that it becomes difficult to capture, aggregate, analyze, store, process, share, or visualize them using traditional data processing applications In healthcare, the term Big Data can apply to a wide range of datasets including: Clinical data diagnoses, disease patterns, clinical outcomes, co-morbidities, readmissions, clinical site infections, etc. Financial data costs, pricing, charges, coding, billing, accounts receivable, payments (credit balances, underpays, and denials), etc. Population Health Management data membership and eligibility, utilization, physician practice patterns, leakage, etc. 2

4 Big Data Regulatory Reforms Quality Reporting Value Based Purchasing Focus on Outcomes Economic Pressures Fee-for-service Declines At-Risk Contracting Need for Increased Coordination Consumerism Quality & Cost Comparisons Access to Data/ Interoperability Demand for Transparency Big Data and Advanced Analytics is essential to flourish in today s changing Healthcare environment 3

5 Sample Healthcare Big Data Sets Sample Data Source Standard Charge Data Claims Paid Data Total Cost of Care Data Quality of Care Data Milliman & Robertson MEDPAR State Agencies (e.g. VHCURES) Blue Health Intelligence Truven Analytics Definitive Optum American Hospital Directory LeapFrog 4

6 Healthcare Applications of Big Data Total Cost of Care Analytics Provider Benchmarking M&A Due Diligence Support Patient Safety and Quality Volume/Revenue Leakage Analytics Business Planning and Forecasting Rate Benchmarking/ Rate Parity Patient Risk Stratification Population Health Management Market Share Analytics At-Risk and Value-Based Contracting Potentially Avoidable Complications Strategic Pricing/ Pricing Transparency Chronic Disease Management Community Health Needs Assessment Clinical Guideline Analytics 5

7 Revenue Enhancement Opportunities Total Cost of Care Analytics Provider Benchmarking M&A Due Diligence Support Patient Safety and Quality Volume/Revenue Leakage Analytics Business Planning and Forecasting Rate Benchmarking/ Rate Parity Patient Risk Stratification Population Health Management Market Share Analytics At-Risk and Value-Based Contracting Potentially Avoidable Complications Strategic Pricing/ Pricing Transparency Chronic Disease Management Community Health Needs Assessment Clinical Guideline Analytics 6

8 Rate Benchmarking & Rate Parity Analyses Rate Benchmarking: an independent, 3rd party comparison of contract rates to the area average using commercially available claims paid databases. Often used in strategic contract negotiations. Big Data: Increases statistical significance Improves reliability of the results Allows for a lower level of specificity Rate Parity Analysis: independent, 3rd party assessment of contract rates relative to market competitors. Often used to mediate contract reimbursement disputes. Big Data: Allows for data extraction independent of the 3rd party payer 7

9 Rate Benchmarking & Rate Parity Analyses Aggregate Impact Understand financial impact across the entire system, among hospitals, and major service categories (IP, OP, Physician, etc.). $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $0 $5,897,463 $4,364,000 $2,949,231 $2,183,000 IP Low IP High OP Low OP High $4,000,000 $3,500,000 $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $0 $3,725,497 $672,277 $16,919 $33,312 SJ SM HVI HC HMO IND PPO Service Line Assessment Understand financial impact at the service line level (IP and OP). Service Category Opportunity Low Opportunity High % Below the Area Average Behavioral Health $123,000 $246,120-77% Cardiac $84,605 $169,210-16% General Surgery $344,382 $1,088,764 1% Neurology $363,839 $727,639-36% Neurosurgery $92,237 $184,473-7% OB $348,757 $1,097,514-40% Rehab $72,383 $144,766-38% 8

10 Rate Benchmarking & Rate Parity Analyses Procedure Code Impact Understand financial impact at the individual procedure code level. CPT Code (ER Visit) Area Avg. Contract $193 $405 Area Avg. Contract DRG 460 (Spinal Fusion except cervical w/o MCC) $12,910 $29,917 $0 $100 $200 $300 $400 $500 $0 $10,000 $20,000 $30,000 $40,000 9

11 Strategic Pricing Strategic Pricing: a re-balancing of the CDM that protects revenue while meeting pricing transparency objectives. Well designed studies include: An understanding of the enterprise-wide strategic plan A trend analysis of historical utilization over a multi-year period An analysis of local demographics An analysis of contract terms and their impact on pricing Big Data: Promotes a better understanding of local demographics and its potential impact on service line demand Allows providers to compare unit prices (at the procedure code level DRGs, CPT codes, HCPCS, etc.) to the market 10

12 Strategic Pricing Revenue Center Performance Understand which hospital entities, service lines, and/or CDM codes generate the most revenue. Inpatient 7% 11% 13% 1% 2% 6% 14% 29% 16% Pharmacy Laboratory Respiratory therapy Medical records Radiology Emergency room Operating room Central supply Physical therapy Local Demographics Understand how prevailing and future demographic trends impact utilization, the pricing strategy, and the enterprise-wide strategic plan. People 70% 60% 50% 40% 30% 20% 10% 0% Gender Trends F M While shrinking, there is more female volume than male volume There is a spike in age cohorts 0 15, & The white and black populations are going in opposite directions. Percentage of Population People 30,000 25,000 20,000 15,000 10,000 5, % 60% 50% 40% 30% 20% 10% 0% Age Trends Race Trends A H N U B I O 11

13 Strategic Pricing Payer Performance Understand how payer volume, contract terms, and even contract rates impact standard pricing. 1% 2% 2% 2% 0% 1% 6% 1% 3% 4% Medicare UHC BCBS Self Pay Medicaid Aetna Coventry Care Improvements 8% Amerigroup Wellcare Cigna 15% 18% Humana Other Universal Peach State Note: Charts above should be viewed as examples and not as actual data 12

14 Value (at-risk) Based Contracting The move from volume (FFS) to value (at-risk) has moved from concept to reality In value based contracting, understanding and managing utilization is critical to success Big Data allows providers to understand how they compare relative to the market in terms of utilization (at both the unit and episodic level), price (charges, payments, etc.), and quality of care (readmissions, never events [hospital acquired conditions], etc.) 13

15 Value (at-risk) Based Contracting Total Cost of Care Analysis: An analysis of the total cost (price or payment rate) and clinical outcome of providing a specific episode of care (e.g. pneumonia) from diagnostic testing and the E.R. to inpatient admission, step down facilities, and home health Results allow providers to determine which services can go at-risk and for what price Big Data: Without Big Data, providers only have insight into their own practice patterns, utilization, and clinical outcomes. With Big Data, providers are able to understand how they compare relative to the market and the risks associated with value based contracting. 14

16 Value (at-risk) Based Contracting Total Cost of Care Analysis Case Study A leading cancer center analyzed 4 years of regional claims data for several cancers using a Big Data source. The analysis focused on total cost of care (TCOC) over longitudinal episodes Wanted to understand whether TCOC and patient outcomes were better at their center relative to the market Claims Data Medications Patient Cohorts Procedures Analysis of Total Cost of Care (TCOC) Impact of Treatment location on patient outcomes & costs Referral Patterns Adjusted for Severity Phase 1 I Phase 2 Phase 3 Approach Definition of cohorts, patient attribution to different centers Compute TCOC, outcomes for care across centers Visualization/Analytics to determine impact of care site on TCOC Goal: Assess if Cancer center s high quality care processes are reflected in lower reimbursement and improved outcomes across the episode or continuum of care. Develop a business case for the preferred use (e.g. narrow network participation) of their facility for Cancer Care: Short term goal of increased volume Long term goal of inclusion and revenue protection 15

17 Volume/Revenue Leakage Analytics Volume/ Leakage Analytics Where do patients travel through the continuum of care? What are physicians referral patterns? What can be done to capture more clinical care and referrals? Impacts volume for FFS payments Protects value based payments by ensuring care is delivered by physicians that follow treatment patterns and clinical pathways resulting in high quality outcomes Big Data: Provides the data (physician referral patterns, site of healthcare delivery, spend, etc.) necessary to understand what happens to patients once they leave the system 16

18 Volume/Revenue Leakage Analytics Major Joint Procedure $9,040 $11,066 Other Orthopaedics $3,369 $7,726 Cardiology $2,912 $6,481 General Surgery $2,866 $6,830 Pulmonary $2,620 $8,403 Spine $2,486 $4,561 General Medicine $2,044 $5,966 Gastroenterology $1,926 $4,074 Open Heart $1,182 $2,746 Nephrology $1,157 $2,883 Surgical Tracheostom $1,152 $2,990 Neurosurgery $1,053 $2,140 Oncology/Hematology $970 $2,404 Neurology $968 $3,218 Vascular Surgery $855 $2,466 Thoracic Surgery $567 $1,800 Other $3,041 $20,059 Medicare Payments Patient Universe Medicare Payments THP Plano ABC hospital saw 8,916 unique Medicare patients in 2013 generating $38M in inpatient payments. This represents 40% of total inpatient payments for this patient group. Where did the 8,916 unique Medicare patients go for services in 2013? This patient group generated $11M in payments for Major Joint procedures in ABC Hospital represents 73% of those payments with $8M. This patient group also sought services at the following facilities: 1. DEF Medical Center ($5.4M) 2. Med Ctr of PLACE NAME ($4.4M) 3. HIJ Rehab of PLACE NAME ($3.2M) 4. KLM Rehabilitation Hospital ($2.7M) 5. OPQ Institute for Rehab ($2.6M) 6. RST Med Ctr ($2.5M) Dollars above shown in Thousands Source: Medicare SAF Data 1/1/ /31/

19 Key Infrastructure Needs Subject matter professionals with expertise in: Analytics Advanced modeling technologies Value based contracting Advanced Modeling and Visualization Technology Low tech solutions can pose capacity problems New technologies offer more advanced visualization techniques 18

20 Questions 19

21 Thank you Presentation by Patrick Spoletini Managing Director KPMG Healthcare Advisory

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