The case for claims data aggregation

The Case for Claims Data Aggregation In this new environment of paying for value rather than fee for service, Comprehensive Primary Care initiative (CPC) being a premier example, everything depends on the measurement of value. If we get it wrong the whole movement falters. In the fee for service world much has been done to define “services”, no less important is a standard definition and agreement on what is “value”. This measurement of value to a reasonable degree has to be accurate, above reproach and comprehensive.

It cannot represent a piece of performance or ignore the context of related metrics if it is to provide an overall picture of a practice. It must represent a significant sample size of the practice to avoid the perception that a blip in performance is representative of the overall performance.

For as long as health plans have existed there has been an ongoing laborious debate between providers and plans as to whose data is accurate, what it represents and how it should impact payment. Health plans have been largely blind to quality outcomes and physicians have been largely blind to cost outcomes. In this day of value both need to be present and accounted for. The accounting cannot legitimately be done by either side. It requires a neutral source of truth for us to progress beyond the “head butting” that takes up so much of our time and effort.

Not only can neither side do it on its own, neither side should pay for it alone. Whoever pays for the aggregation of data will have control of the process to a lesser or greater degree regardless of attempts to build-in transparency. If we are to truly have a neutral space it requires shared financing. Joint ownership provides for transparency with regard to vendor oversight, understanding methodology, access to data, avoiding suspicion of a “black box”, and providing a good prototype for future expansion.

1. Value to health plan: In the absence of a data aggregator most if not all of the payers have developed their own methodology for shared savings using the agreed upon metrics but collecting data only on their own membership. This has several disadvantages which could be addressed with a data aggregation approach: a. The inability to have sufficient volume with individual practices thus requiring the empanelment of practices. This approach defaults to evaluating the value of systems or groups of independent practices. It does not credibly evaluate the value at the practice level which is the new functional unit of team-based care. Aggregating the results from as few as three physicians in a practice across a majority of their patients approaches an actuarially sound number for the purposes of evaluating cost outcomes. b. If payers want to know if this new payment for value is valid it will require a robust data base to prove the concept. Even Medicare Fee for Service would by and large not have adequate membership in an individual practice to demonstrate conclusively whether the new pay for value methodology actually reduced cost and/or increased quality and patient satisfaction. c. While we are starting with the measurement of cost and utilization in our data aggregation strategy, eventually the plans would benefit most from a comprehensive view of quality

within a practice. If we start with an infrastructure that is payer specific, it builds the infrastructure on which clinical results can be super-imposed. d. Only by translating the varied payer contract arrangements with providers to a standard cost, e.g. % of Medicare, could an apples-to-apples comparison be done across practices.

This additionally protects plans from divulging proprietary contracting amounts among themselves and providers.

2. Value to practices: a. A trusted co-owned source of data is needed for providers to put forth the effort to improve their outcomes and engage payers in value discussions; eliminating the “black box” effect. b. There is efficiency to be gained by the practices when they can focus on a standard set of metrics and benchmarks as they improve their performance. Even if they had different goals of performance depending on their individual agreements with health plans, they would not have to devise a new set of metrics or measurement methodology. c. The tracking of attribution that would be possible through aggregation of claims could provide an immediate benefit by bringing about more timely capture of the market churn as employers and individuals migrate between plans. d. Without a true aggregated number each practice would be at the mercy of a payer’s definition of cost and utilization. In order to have an accounting of cost a standardized linking of cost to a “gold standard” would be necessary in order to make sense of cost information provided across payers. Only by translating the varied payer contract arrangements with providers to a standard cost, e.g. % of Medicare, could an apples-toapples comparison be done across practices. This additionally protects plans from divulging proprietary contracting amounts among themselves and providers. e. A standard approach to risk adjustment provides greater confidence that a fair process for addressing case mix and severity of illness is applied uniformly.

In conclusion there needs to be a neutral space in which both providers and payers can meet and have confidence in a process that accurately measures and compares performance data in both quality and cost. This function needs to be co-owned. This function needs to be done by an organization that has an ongoing trusted relationship with both providers and payers and have personnel that are easily accessible and accountable.

Comprehensive View No one payer can do it alone: To have an actuarially sound assessment of a practice’s value. A majority of the patients need to be included. Paying for value requires measurement of value at the practice level; the new functional unit of health care.

T he Case for Claims Data Aggregation

Measurable Value Combined Data enables measurement of ‘Pay for Value’ Models, giving a statistically valid and comprehensive view of a practice’s performance compared to market aggregate.

Value for Payers

Standard Approach Health plans can rely upon a standard measure set that has been adopted from national standards.

Measuring what has demonstrated importance and currency with employers.

A sustainable and scalable approach relies on the accuracy of aggregated data. Co-Ownership and accuracy provide payers with the confidence needed to attach payment.

There is efficiency to be gained by the practices when they can focus on a less variable set of metrics and benchmarks as they improve their performance.

A trusted, co-owned source of data is needed for providers to put forth the effort to improve their outcomes and engage payers in value discussions; eliminating the “black box” effect.

Value for Providers After years of getting individual plan reports, physicians will have a true picture of their total practice’s performance, which they can rely on for improvement and negotiations with payers.

Physicians have long known that the services they provide beyond the 15 minute office visit have been undervalued. True value stems from the coordination and follow up, which can now be captured.

Sustainability