Uniting Lab and Claims Data for Next Gen Predictive Analytics...3 Session Objectives •Gain an...
Transcript of Uniting Lab and Claims Data for Next Gen Predictive Analytics...3 Session Objectives •Gain an...
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Proprietary and Confidential. Blue Health Intelligence (BHI) is a trade name of Health Intelligence Company, LLC
Uniting Lab and Claims Data for Next Gen Predictive Analytics
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Our Speakers Today
Frank JacksonExecutive VP - Payers
Prognos
Roxanna CrossAVP, Product Management
BHI
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Session Objectives
• Gain an understanding of the predictive value of clinical lab data
• Learn about approaches used by Prognos that help overcome the challenges of acquiring electronic lab results data
• Understand a use case where combining lab and claims data improved predictive performance
BHI and Prognos share experiences combining lab and claims data in the development of predictive analytics and machine learning models
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Why clinical lab data?
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Lab Data Drives Key Decisions But Highly Underutilized
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70% of Treatment Decisions are Based on Lab Results
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Augmenting Claims with Disease Severity / Progression Creates New Insights
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The Power of Prognos AI and Clinical Data
Significant Curation of Lab Results Required to Make Smart Data
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How Prognos Converts “Raw Data” into “Smart Data”
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Lab Results are Clinically Deciphered
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Clinical rules and medical guidelines are applied to normalized lab results to make actionable
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Lab Relationships for Member Level
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Prognos' Application of Machine Learning
Underwriting/Member Risk Predictor AI Models to Predict Group & Member 12 month Costs
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Risk Adjustment
• Predicts gaps in diagnosis coding
• Models for high volume / high revenue impact HCCs that are industry ‘problem areas’
Capture more hard to detect understated risk with
significantly less wasteful medical record reviews
Cost & Risk Predictions
• Total Cost of Care
• HiCCs (>250K, >100K, other thresholds)
• Potentially Avoidable Events
• High Risk Events
An ensemble of models for rare, difficult to predict,
reoccurring and emerging high cost members
Intervene earlier to mitigate avoidable events& progression to higher cost
Automated Personas & Prescribed Actions
• Predicts and clusters members into groups to surface and prioritize opportunities for cost mitigation and improved outcomes
• Identifies medical, socioeconomic, andbehavioral areas of impact with prescribed actions
BHI’s Application of Machine Learning
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BHI’s algorithms are proven accurate and transparent with more precise targeting to significantly reduce wasteful reviews
We continually measure to improve
Individual risk scores drive payment
▪ Diagnosis codes on claims notoriously understated
Hundreds of thousands of medical record reviews to close gaps
▪ Significant # of wasteful reviews
Risk Adjusted Payment Systems: The Business Problem
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Measure and ImproveA Comparison of Past & Current Performance
• The Baseline (to improve from)• A large Medicare Advantage population
• 2016 results of 500K+ MMRs
• Charts reviewed for 90%+ of MA members
• gaps identified by a prior vendor’s algorithms
A retrospective comparison performed by BHI in collaboration with a Plan
• The Comparison
Prior Algorithms
BHI Algorithms
Top High-Volume Condition Groups
Volumeof MRRs
Captured Comparable
RevenueAccuracy
Significantly Less %of MRRs
Cardiovascular 88K 103% 18%
Psychiatric Disorders
43K 85% 34%
Neoplasms 57K 106% 16%
Endocrine 63K 80% 35%
Vascular 62K 95% 28%
Prior Algorithms
BHI Algorithms
MRR Targets 500,382 116,447
MRR Targets Closed
10,535 11,026
Closure Rate 2% 10%
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Measure and ImproveA Comparison of Past & Current Performance
• The Baseline (to improve from)• A large Medicare Advantage population
• 2016 results of 500K+ MMRs
• Charts reviewed for 90%+ of MA members
• gaps identified by a prior vendor’s algorithms
A retrospective comparison performed by BHI in collaboration with a Plan
Prior Algorithms
BHI Algorithms
MRR Targets 500,382 116,447
MRR Targets Closed
10,535 11,026
Closure Rate 2% 10%
• The Comparison
Even if ROI stronger to chase less, Plans are cautious about reducing reviews when understated risk accuracy is at stake
There were more complex patterns out there to be discovered
Total Revenue $$ Captured
from doing 500K+ MRRs
$$Not Targeted $$
Targeted
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Why a Machine Learning Model?
• Machine learning excels at finding insightful patterns from data. It can rapidly find patterns to shortcut the laborious process of algorithm development.
• Important to expand to include clinical data to increase predictive power. Lab data is messy and algorithm development for LOINC codes and other clinical observations is laborious requiring many hours of clinical review.
• Augment existing algorithms with a machine learning model to capture more hard to detect understated risk with significantly less wasteful medical record reviews
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• HCC 18 – Diabetes with chronic complications
• HCC 108 – Vascular disease
• HCC 22 – Morbid obesity
• HCC 111 – COPD
• HCC 85 – CHF
• HCC 161 – Chronic ulcer of skin,except pressure
Models to Compliment Existing Gap Identification Algorithms
Models trained for selectHierarchical Condition Categories (HCCs)
➢ High Volume
➢ High Revenue Impact
➢ Plans typically experience low closure
➢ Plans are finding a high degreeof revenue closed not targeted
Gradient Boosting Models with hundreds of input variables:
• 1,789 with lab variables
• 1,276 without lab variables
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Diabetes with Chronic Complications
Machine Learning + Algorithms outperformed traditional methods
What was measuredBaseline
YearBHI
AlgorithmsBHI Algorithms + Machine Learning
Targeted Gaps 100%41%
of baseline targets
60%of baseline
targets
Closure Rate 10% 23% 21%
Revenue Captured and Targeted 78% 72% 94%
• Prediction threshold 10% and greater
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Vascular Disease
Machine Learning + Algorithms outperformed traditional methods
Baseline Year
BHIAlgorithms
BHI Algorithms + Machine Learning
Targeted GapsBaseline
(100.0%)
29%of baseline
targets
67%of baseline
targets
Closure Rate 2% 6% 5%
Revenue Captured and Targeted 61% 51% 88%
• Prediction threshold 3% and greater
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COPD
Machine Learning + Algorithms outperformed traditional methods
BaselineYear
BHIAlgorithms
BHI Algorithms + Machine Learning
Targeted GapsBaseline
(100.0%)
31%of baseline
targets
49%of baseline
targets
Closure Rate 8% 27% 25%
Revenue Captured and Targeted 58% 60% 75%
• Prediction threshold 10% and greater
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CHF
BaselineYear
BHIAlgorithms
BHI Algorithms + Machine Learning
Targeted GapsBaseline
(100.0%)
32%of baseline
targets
40%of baseline
targets
Closure Rate 3% 9% 10%
Revenue Captured and Targeted 58% 57% 74%
Machine Learning + Algorithms outperformed traditional methods
• Prediction threshold 10% and greater
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Morbid Obesity
Machine Learning + Algorithms outperformed traditional methods
BaselineYear
BHIAlgorithms
BHI Algorithms + Machine Learning
Targeted GapsBaseline
(100.0%)
44%of baseline
targets
63%of baseline
targets
Closure Rate 8% 27% 25%
Revenue Captured and Targeted 37% 53% 70%
• Prediction threshold 10% and greater
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Chronic Ulcer of Skin
Machine Learning + Algorithms outperformed traditional methods
BaselineYear
BHIAlgorithms
BHI Algorithms + Machine Learning
Targeted GapsBaseline
(100.0%)
30%of baseline
targets
34%of baseline
targets
Closure Rate 2% 5% 6%
Revenue Captured and Targeted 42% 38% 51%
• Prediction threshold 10% and greater
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Overall Impact for the Six HCC Condition Models
Machine Learning + Traditional Algorithms outperformed all
Baseline Year
BHIAlgorithms
BHI Machine Learning
BHI Algorithms+ Machine Learning
Targeted GapsBaseline
(100.0%)
33%of baseline
targets
41%of baseline
targets
55%of baseline
targets
Closure Rate 5% 13% 14% 11%
Revenue Captured and Targeted 59% 58% 71% 80%
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Impact of Adding Lab Results Data
Machine Learning with lab data performed better than without lab data
• BHI’s experience adding electronic lab results to methods
• A 10% improvement in revenue capture potential for select conditions
• Even a 1% improvement can result in millions of dollars in enhanced revenue accuracy (depending on size of health plan)
• BHI believes even greater increase is achievable through more complete acquisition of lab results data
• Prognos’ experience adding electronic lab results to claims only methods
• A 15% improvement in revenue capture potential
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Wrap Up
• Large datasets are essential to build high performing predictive models
• Combining claims data with clinical data increases predictive power
– 70% of Treatment Decisions are Based on Lab Results
• BHI and Prognos are committed to partnerships that expand value to Blue Plans by combining areas of specialization