4 Ways Claims Data is Changing Care Delivery

Fragmented clinical data, which tends to cause disjointed care, can be significantly augmented by data in health plan claims. At Parkland Health & Hospital System in Dallas, physicians are using claims data to increase quality and decrease costs.

A formerly underused tool that can elicit better outcomes and lower healthcare costs is being embraced by clinicians in Dallas.

At Parkland Health & Hospital System—a Dallas-based public health system that includes the 835-bed Parkland Hospital—health plan data is a key component to redesigning care to enhance outcomes, lower costs, and "improve the experience for the patient and for the provider," says Barry S. Lachman, MD, medical director of Parkland Community Health Plans.

Parkland Community Health Plans is a Medicaid-managed care plan designed to connect adults and children to affordable healthcare through a patient-centered medical home model.

Figuring out how to harness data in meaningful ways will be critical to success for healthcare organizations as the industry continues to move toward value-based care and population health management strategies.

"Our perspective on our role is that we are here to benefit the health of the community. We are not just here to pay claims… We are here to address all of our communities' health needs," Lachman says.

1. Closes Information Gaps
Because the nation's healthcare system is so large and so complex, it is common for gaps in information to exist as patients move among providers. Fragmented clinical data, which tends to cause disjointed care, can be significantly augmented by health plan claims, says Donna Persaud, MD, Parkland's chief of pediatric population division.

"What I have learned in this role as we move to transformative care, is that what insurance does for a patient is it ties them with an identifying number such that utilization can be tracked, and that tells the story of their lives in terms of care coordination," she says.

"The health plan has claims data and that is all-inclusive of where the patient has been in the system. There are huge opportunities for what providers can do if they are aware of that information."

For example, Persaud says, physicians can use the additional data to gain a more complete picture of patients' utilization patterns and to better tailor care plans to meet their needs.

"This care redesign comes from learning from the data what you can do that will result in better outcomes. That increases quality and decreases costs," she says.

2. Identifies Social Barriers
Health plan data also provides a more complete picture of patients' lives outside of the healthcare system, including the social determinants that may make it difficult for them to follow a care plan to recover and manage their health, Lachman says.

"One of the big problems with data that you have in a health system is that data in an EHR is a mile deep and an inch wide. It doesn't tell you anything about what is going on in the patient's life or the rest of the healthcare space," he says.

"Providers are trying to provide care, but unless they specifically ask patients or the patient tells them, they have no idea [about the social issues that could be impacting their health]. Having a health plan with data provides a way of looking at the patient's total life."

And without knowing what is happening with the patient beyond the four walls of the hospital or doctor's office, Lachman says, it can be impossible for a physician to help patients make significant gains with their health.

For instance, he says, when he participated in a community health walk through of a Dallas apartment building, he saw the kinds of environmental factors that physicians need to be aware of in order to coordinate the most impactful care and services for patients.

"I saw conditions in those apartments with the ceilings falling in and mold on the walls. Asthma is a major health issue, and we can throw all the asthma medicine in the world at the people who live in these apartments … but until we get to the root cause, we are just putting a Band-Aid on the problem, and we are wasting public money."

The claims data "tells the story" of patients' lives and is a critical part of being able to design successful care plans, Persaud agrees.

"What we are trying to aim for is designing care that is integrated into patients' lives and that is applicable to the way patients actually live. That is the way patients are going to get better and that costs will go down," she says.

"We are reorganizing and transforming what we do for patients because the social conditions around poverty, which affect food security, literacy levels, and transportation access, also affect their ability to receive care that is effective for them."

3. Aids Coordination With Other Agencies
When social issues are identified, Parkland's clinicians refer patients to outside social services organizations. Parkland is working more closely than ever with community agencies as a way of assisting patients in accessing the necessary resources to deal with social barriers.

Clinical and health plan data are important tools for knowing whether patients are actually receiving that social support, Persaud says.

"We are leveraging technology because that becomes big in this when we are looking for ways we can coordinate with other agencies… We use technology to look at what ways we can know that patients got those resources and know that these mechanisms that allow them to access other agencies are working to support them in their lives. [This enables us to] know that they are following through on the care we are recommending."

Although health systems have not always worked in such close association with social service agencies, Lachman says, a new sense of cooperation is emerging because the links between social determinants and good health are too strong to ignore.  

"Having been involved in healthcare for the underserved for over 40 years, I have seen a gradual transformation of people realizing the importance of coordinating care," he says.

"I'm not quite sure we are at the tipping point, but we are sure getting there. I think the transformation was happening before the Affordable Care Act, but a number of things in the Affordable Care Act are really encouraging more collaboration and cooperation and have helped move us forward."

4. Provides Predictive Analytics
Along with Parkland's healthcare delivery network and health plan, the integrated system also includes the Parkland Center for Clinical Innovation, a non-profit research and development corporation that specializes in real-time predictive and surveillance analytics for healthcare.

PCCI uses Parkland's clinical and claims data to produce predictive analytics that allow providers to take a more sophisticated and evidence-based approach to care delivery.

"The trifecta of all that activity is beginning to provide important results for us and is now increasing our ability to reduce things like complications from chronic conditions, hospitalizations, and ED visits," Persaud says.

"One way we have used analytics is to predict risk scores for utilization and to determine who is going to end up in the ER or be hospitalized, who is the sickest, who is the most likely to have complications of their condition or instability… It allows the healthcare team to prioritize the resources around who will likely decline the most or have the worst outcomes or utilization issues."

Additionally, the analytics are an important resource for physicians to be able to identify patients whose health conditions and social barriers put them in the category of rising risk, Persaud adds.

"It also allows us to stratify everyone else and to straddle resources across the spectrum to prevent the movement of patients from low to high risk."