Post on 14-Nov-2014
description
© Health Market Science 2013, All Rights Reserved
Zach HendersonClick icon to add picture
SVP, Healthcare Markets
Connected Insight Summit
DATA-TASTICK
A Deep Dive on Data Driving Networks
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It’s time to get excited about data…
We all think of
Data
in different ways
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If you’re like me, as a bunch of 1s and 0s flowing through the pipes of healthcare processing streams…
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To many, it’s simply the content in spreadsheets…
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For some, data is a little more simple than that…
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Data often gets front page billing…
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And some think of “Data” quite differently…
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Data is sometimes frustrating…
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And data became worse when it got “Big”
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But when we finally understand Data, it is great!
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We are in the Healthcare track at this conference after all
BUT LET’S GET MORE SPECIFIC
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Type of Data Benefits Caveats
Prescription/Rx Claims
• Concentrated sources… easier to collect• Excellent for tracking retail pharma products• High coverage with weekly updates available• Known denominator
• Only usable for retail tracking• Variable correlation between Rx activity and medical activity
Medical Claims
• Tailored to diagnosis and procedure codes of interest• Covers both retail and non-retail settings• Best for identifying “splitting” behavior of procedures • Closest correlation to actual referral networks
• Severely fragmented• Difficult to source• No standard denominator/total• Latency
What types of data are available?
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Where do medical claims come from?
Payers
+4,000
835
State Databases& Collaboratives
Office Practice Management Software
+500
Claims Switches/Clearinghouses
837
+50
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• UB-04• Institutional claims for services provided by hospitals, hospices,
and long-term care facilities (e.g. SNFs) are billed on Uniform Bills (UB-04 or CMS-1450, formerly UB-92)
• All services are summarized by revenue codes
• For inpatient claims, UB-04 describes procedures primarily by ICD-9 procedure codes
• For outpatient claims, UB-04 describes the services and supplies provided by using CPT and HCPCS codes
• 1500• Professional claims for services provided by physicians, labs,
ambulances, and DME vendors are billed on CMS 1500 forms (HCFA 1500 or 1500 forms)
• CMS 1500 always describes the services and supplies provided by using CPT and HCPCS codes
Types of Claims Forms (UB-04)
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Medical Claim Form
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Drug Name & Strength, NDC: 12345-6789-01
01 06 03 01 06 03 11 1 99211 1 $$ $$
01 06 03 01 06 03 11 1 90782 1 $$ $$
01 06 03 01 06 03 11 1 J9010 1 $$ $$
123-45-6789 xxx xx
John Brown, M.D.111 Hospital DriveAnytown, USA 12345
123-45-6789 xxx xx
• Glean useful information:› Physician ID,
diagnoses and procedure codes, facility ID, etc
Drug Name & Strength, NDC: 12345-6789-01
01 06 03 01 06 03 11 1 99211 1 $$ $$
01 06 03 01 06 03 11 1 90782 1 $$ $$
01 06 03 01 06 03 11 1 J9010 1 $$ $$
123-45-6789 xxx xx
John Brown, M.D.111 Hospital DriveAnytown, USA 12345
123-45-6789 xxx xx
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Diagnosis Code:ICD-9-CM code for appropriate diagnosis or nature of illness
Office Visit Code:CPT code for services provided to an established patient
Procedure Code:CPT code for an injection
Required: Drug CodeAppropriate HCPCS Drug Code
for medication administered
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We almost forgot the most important part…
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Drug Name & Strength, NDC: 12345-6789-01
01 06 03 01 06 03 11 1 99211 1 $$ $$
01 06 03 01 06 03 11 1 90782 1 $$ $$
01 06 03 01 06 03 11 1 J9010 1 $$ $$
123-45-6789 xxx xx
John Brown, M.D.111 Hospital DriveAnytown, USA 12345
123-45-6789 xxx xx
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197 7
Drug Name & Strength, NDC: 12345-6789-01
01 06 03 01 06 03 11 1 99211 1 $$ $$
01 06 03 01 06 03 11 1 90782 1 $$ $$
01 06 03 01 06 03 11 1 J9010 1 $$ $$
Patient Information:The details on the unique patient
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But that is HIPAA data!!!
Patient 123456
Date of Birth
First NameLast Name
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Magical Encryption/De-identification
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So what?
SpecialistPatient 123456
Cardiac SurgeonPatient 123456
PCPPatient 123456
WHY DO YOU CARE?
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Grow system/ACO through acquisitions, partnerships and recruitment
10% 20% 30%
Understand where there is opportunity to grow referrals
Identify areas of patient leakage
70%
20%
10%
Know where splitters are “splitting”
First off, healthcare companies can do a lot with data
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Physician to Physician relationships are important
Medical claims data can be used to derive physician-physician relationships based on shared patients for a disease state of interest.
Analytic methodologies can leverage longitudinal tracking of patients across physician visits by leveraging an anonymized patient ID.
A pair of physicians that share a statistically significant number of patients within a specified time window are assumed to have a professional relationship.
Is it a leap?
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Example Network for a Service Line
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Georgia network
Atlanta networkZoom in to portion of Atlanta network
Dr. Ruth O’Regan
Dr. Ashesh Jani
Dr. Monica Rizzo
Relationships for Dr. O’Regan
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Barbara VizyFamily Practice3690 Orange PlBeachwood, OH
A Provider Centric View of Competition in Cleveland
Dr. Michael WalkerSurgery, Orthopedic9500 Euclid AveCleveland, OHOrtho National Rank - 9
Xian JinInternal Medicine9500 Euclid AveCleveland, OH
Ranjit TamaskarInternal Medicine20000 Harvard AveBeachwood, OH
Strength of Relationship
10
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Andrew BrobbeyInternal Medicine25701 N Lakeland BlvdEuclid, OH
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Walker
Jin
VizyBrobbey
Tamaskar
10
7
8
10
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Shows a Referral Source that has relationship with 2 different systems
Dr. Ranjit TamaskarInternal Medicine2000 Harvard AveBeachwood, OH
Michael WalkerSurgery, Orthopedic9500 Euclid AveCleveland, OH
William PetersilgeInternal Medicine20000 Harvard AveBeachwood, OH
Strength of Relationship
10
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Tamaskar
WalkerPetersilge
10
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Now that you can “see” how the data relates, it’s time to put data into action
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Zach Henderson
SVP, Healthcare Markets
QUESTIONS
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