The state agency, which administers health benefits for 205,000 employees and dependents, set out to identify the cost and outcomes of the ACA-required preventive cancer screenings. What the agency really wanted to know was whether the screenings were resulting in earlier cancer detection, which in turn required less invasive and less costly treatment.

For quite some time, the agency simply assumed that the screenings were cost effective. The challenge was to accurately quantify their impact at a time when:

• The American Cancer Society (ACS) released new, more targeted guidelines that lowered the number of people it recommended for the preventive screenings.¹ (The ACS believed the change would result in higher prevention rates even with fewer people screened.)
• Screening utilization was declining.
• Only 6 to 8 percent of members who were screened were actually diagnosed with cancer or a related condition as a result.

The state agency’s population health manager (PHM) uses HDMS’ analytics and reporting solution on a quarterly basis to analyze trends in cost and utilization of employee benefits. With HDMS’ data management expertise, the PHM trusted the credibility of the analysis. To further evaluate the cancer screenings, the PHM took advantage of the solution’s built-in evidence-based guidelines to create episode-based analysis groups (cohorts) from claims and enrollment data to measure whether members:

• Were diagnosed with any cancer within the three years prior to being diagnosed with breast, cervical, uterine or colorectal cancer. (This helped to identify new cancer cases as opposed to recurring cancer cases.)
• Received medical services for a cancer diagnosis within 60 days of a preventive cancer screening.

Analysis clearly showed the value of preventive cancer screenings for members and for the state agency:

• The majority of new cases of breast, colorectal and cervical cancer among the agency’s members were initially diagnosed as a result of preventive screenings.
  • 80% of new cases of breast cancer were associated with preventive screenings¹
  • 11% of members who received screenings received additional treatments – not just for cancer
  • Cervical cancer screenings led many members to additional uterine or ovarian testing
• Members diagnosed with breast, cervical, uterine or colorectal cancer through the preventive screenings experienced fewer medical complications, as shown through lower relative health risk scores.
  • Breast Cancer
    • 00 Average risk score of members diagnosed with breast cancer
    • 88-6.53 Average risk score of members diagnosed with breast cancer
  • Cervical Cancer
    • 00 Average risk score of members diagnosed with breast cancer
    • 31-4.22 Average risk score of members diagnosed with breast cancer
  • Those diagnosed through preventive screenings recorded lower total costs of cancer care on a risk-adjusted cost basis, as well as relative to expected cancer treatment costs.
    • 9% Decrease in the cost of treatment for breast cancer
    • 6% Decrease in the cost of treatment for colon cancer
  • Overall, paid claims for all three types of cancer screenings was 3.6 percent lower than in previous years.

Today, the state agency reviews a preventive screening dashboard every quarter to monitor outcome metrics. Furthermore, working together with HDMS to perform proactive data analysis may open up new insights into opportunities to reduce costs and improve member health. It’s just one powerful illustration of how robust data analysis can help employers and health plans measure and enhance the effectiveness of preventive health benefits.

¹Grady, D., “American Cancer Society, in a Shift, Recommends Fewer Mammograms,” The New York Times, Oct. 20, 2015, https://hms.harvard.edu/news/american-cancer-society-shift-recommends-fewer-mammograms

HDMS proprietary data

In this webinar, HDMS and Meritain Health, a leading national TPA will discuss common challenges that payers face. Through a series of demonstrations, we will share best practices and show to to leverage the power of data to create high-value, actionable information that can be shared within the organization and with the plan sponsors.

During this webinar, payers will learn how Meritain Health, who serves over 2,300 clients nationally, uses proactive analytics to:

• Understand and respond to the drivers of clinical risk over time
• Monitor, manage and take action to move towards desired outcomes
• Use information-driven insights to guide business transformation and clinicial innovation

Learn how this leading TPA is leveraging actionable analytic intelligence to provide their plan sponsors timely information to inform decisions.

Speakers:

• Rob Corrigan, Senior Director, Advisory Services, HDMS
• Shawn Shapiro, Informatics & Data Governance, Meritain Health

There is no shortage of data in health care. Industry stakeholders— employers, plan sponsors, payers, TPAs, health systems and provider organizations—are sitting on vast amounts of raw data, and more is generated and collected every day from a growing number of sources.

Industry estimates indicate only about 20 percent of this data is structured, meaning it is quantitative and objective, including vital signs and health markers like blood sugar and cholesterol levels. Up to 80 percent of health care data is unstructured, or qualitative and subjective, such as patient assessments of pain and level of discomfort gathered during patient encounters.¹

Structured data can reside in digital silos and in differing formats that may present barriers to sharing and analysis. The sheer volume and nature of unstructured data presents even more of a challenge; qualitative data is frequently stored in system text fields, making it difficult to retrieve, interpret and analyze.

The result: despite the large amount of data available, health care organizations don’t always have the right data they need to make effective decisions— especially because system transformation toward value-based care and population health requires different datasets for optimal decision-making.

Proactive analytics is the key to unlocking the value hidden away in mountains of raw structured and unstructured data. The spectrum of analytical capabilities—from descriptive and diagnostic to predictive and prescriptive analytics—is about processing raw data into useable information and turning that information into knowledge and actionable insight. Proactive analytics is about taking action—knowing where and how to act, and measuring the results of those actions.

For health care organizations currently under or transitioning to value-based contracts, proactive analytics offers a tremendous opportunity to optimize performance and gain a competitive edge by addressing affordability and cost concerns, delivering better value to stakeholders throughout the system, and managing through market uncertainty.

HDMS enables health care organizations to seize this opportunity through a powerful analytics platform that securely aggregates and integrates data from any source and performs value-added analytics and reporting that transforms raw data into meaningful information, robust knowledge and actionable insights.

HDMS partners with stakeholders across the health care system that want to move from a reactive reporting model (common in fee-for-service environments) to a proactive, analytically driven solutions model to deliver greater value and better results to their clients and members. Meritain Health is one such stakeholder.

Meritain Health, a leading national TPA, is known for providing its clients with flexible, actionable data solutions, extensive network strategies, and integrated best-in-class partner support. The following use cases illustrate how Meritain’s strong partnership with HDMS has enabled them to deliver best-in-class proactive analytical intelligence and decision support to clients.

Standard health plan reporting shows comparisons of current versus prior periods. This helps identify trends but leads to questions of why there are differences and what is causing the changes. One of the most important ways proactive analytics unlocks value in data is by enabling a deeper understanding of what, exactly, is driving trends. HDMS’ Components of Trend methodology enables clients to drill into and deconstruct data patterns across a variety of components in order to pinpoint why trends are occurring and what is causing them—without undue extrapolation or guesswork.

Use Case 1: Improving Cost Trends

Meritain’s client, a large education system with 30,000 member lives, wanted to understand cost drivers behind a year-over-year increase in plan expenditures in order to reduce risk and lower expenses. Using HDMS’ analytics platform, a Components of Trend assessment revealed the emergency department (ED) service category was significantly affecting overall plan expenses due to inappropriate utilization.

Based on this analysis, Meritain made plan modifications and developed strategies to steer members to more appropriate care, including increased contributions for preventive care and the addition of a telemedicine provider. The changes resulted in a 17.4 percent reduction in ED visits, a 20.1 percent increase in utilization of preventative care, and a 4.2 percent decrease in overall plan spending.

High-cost claimants (HCCs) concern most payers and plan sponsors because although they typically represent about 1 percent of members, they account for 33 percent of spending. Early identification and mitigation strategies can be helpful, but plans are challenged in identifying which members will become HCCs since prior HCC status only predicts future status in 25 percent of cases.²

HDMS’ platform helps plans identify members at risk of becoming HCCs in the next 12 months through use of predictive models based on chronic and comorbid conditions and compliance history. The platform can also predict a program’s effect on members’ health status, enabling clients to offer appropriate services before the member becomes a HCC.

Use Case 2: Reducing HCC Expenses While Improving Health

Meritain’s client, a construction company with 500 member lives, wanted to decrease plan expenses while maintaining the best level of care and improving health outcomes, consistent with the company’s firm belief in investing in their people to drive success. Meritain used the HDMS platform to identify people with a chronic or comorbid condition at risk of becoming HCCs and compare HCC activity with medical and disease management program participation.

The analysis enabled the company to identify at-risk employees, develop early intervention and engagement strategies, and validate the positive effect of medical/disease management programs, leading the employer to provide greater incentives for participation. These strategies led to a 35 percent increase in program participation, a 6.2 percent reduction in HCCs, and overall plan savings of 23.7 percent due to the decrease in HCCs.

According to HDMS client data, specialty drugs cost 10 to 15 times more than traditional drugs and account for about one-third of plan pharmaceutical spending. These costs are projected to grow about 20 percent annually. Managing this spending involves more than focusing on the drugs themselves. Cost must be considered in the context of the member’s medical condition, medication compliance and treatment efficacy.

By linking medical, pharmacy and other data sources, HDMS’ platform captures this holistic view and enables plans to zero in on the practical effect of specialty drug spending and developing strategies for reducing that spending while ensuring quality member care.

Use Case 3: Decreasing Specialty Drug Costs

Meritain’s client, a large education system with 30,000 member lives, wanted to gain a deeper understanding of pharmaceutical utilization and determine opportunities to decrease specialty drug expenses while ensuring quality care for members and improving health outcomes.

Meritain used HDMS’ platform to integrate medical and prescription data for high-cost and high-risk patients, then drilled down to ensure participation in a medical-management program focused on adherence and closing care gaps. When possible, members were moved to a lower dosage and frequency. The results included a 12.2 percent reduction in year-over-year medical expenses for members filling specialty-drug prescriptions and a decrease in specialty drug costs of 19.5 percent.

Strategies to keep members in network provide an effective way to help control plan spending and ensure quality care and better care coordination— particularly important in the era of value-based care. HDMS’ analytics platform features built-in research capabilities for exploring network leakage and identifying members and conditions associated with inappropriate or ineffective out-of-network care, especially in high-cost service areas. These insights inform proactive interventions on both the member and provider side (for example, a member’s assigned primary care physician) to keep care where it is most cost effective.

Use Case 4: Understanding and Stopping Network Leakage

A Meritain hospital system client with 9,000 member lives wanted to gain a deeper understanding of how care was delivered outside their network by analyzing referral patterns, member demographics and treated conditions, as well as address challenges related to domestic providers referring members to out-of-network care.

Using analytical data from the HDMS platform, Meritain was able to recommend interventions, including education and outreach to referring providers, that resulted in 38 percent fewer out-of-network referrals, 14.4 percent greater network use, and an overall reduction of 10.8 percent in the hospital’s medical plan spending.

National leader in third-party plan administration, business process outsourcing, self-funded plan designs, network management solutions and health management strategies

• Over 30 years of experience
• Over 1 million member lives across the U.S.
• Independent subsidiary of Aetna
• 70% increase in member population since 2011

1. Smithwick, J. (2015) Unlocking the value of unstructured patient data. Becker’s Health IT & CIO Review. Retrieved from http://www.beckershospitalreview.com/healthcare-information-technology/ unlocking-the-value-of-unstructured-patient-data.html
2. Wilson, D., Troy, T., Jones, K. (2016) High Cost Claimants: Private versus Public Sector Approaches. American Health Policy Institute and Leavitt Partners.