When the Affordable Healthcare Act (ACA) took effect three years ago, there was uncertainty about how to implement it and how to manage a cost and value picture that would be decidedly different from what it had been in the past.
“For physicians, nurses and other health care workers, learning to work in a more integrated environment, across institutions, will take time,” David Cutler, a Harvard professor and healthcare economics expert, told the Robert Wood Johnson Foundation when the act took effect. Alan Garber, professor of medicine at Stanford University, told the foundation: “The first, and most important piece of this is to get costs down without compromising quality.”
One major area of impact (and neglect) for healthcare institutions and providers is the back office — those administrative functions in the bowels of organizations that process claims, provide feedback on costs, and (until the ACA) focused almost exclusively on a fee-for-service billing model.
I spoke with a representative of ZirMed, which provides revenue cycle management services to healthcare providers. “With ACA, we realized that the market was moving from a fee-for-service to a fee-for-value cost model,” said Mary Hardy, Director of Business Development & Partner Sales. “The critical next step for healthcare institutions and providers was to integrate their communications about individual patients’ care and to coordinate that care with each other.”
In the US, “we spend two times the amount of healthcare dollars per capita as any other country, but our life expectancy is not among the highest,” Hardy said. “One-third of our seniors have more than three chronic illnesses, and 6% have more than six chronic illnesses. It is the expense of these very complex cases that causes healthcare costs to escalate.”
As a cloud analytics provider, ZirMed focuses on information that can assist healthcare institution in the delivery of value-based care. “We do this by aggregating data from a variety of sources. There is claims data with diagnostic codes, which in turn is supplemented with unstructured clinical data such as lab results. There is also claims-based data on medications that patients are taking.”
The goal is to enable healthcare providers to identify unique patterns of illness and treatment that can then be classified to achieve optimal care and outcomes.
“We break the patient population into groups, so if a patient is diabetic, he goes into a diabetics registry,” Hardy said. “For each group, claims payers provide a list of healthcare measures that trigger if a patient has a particular diagnosis. These measures combine quality of care with efficiency of cost for value results that recommend, among other things, how often patients with specific diagnoses should be given certain tests. The goals are to take big data that has been aggregated and to assess it for purposes of optimal healthcare and cost management and also for illness prevention.”
For all this to work, disparate systems with structured and unstructured data must be integrated and secured while always remaining accessible to healthcare teams. It is a daunting task for even large healthcare IT organizations — and a virtually impossible job for small clinics and providers.
“When we looked at the industry and the challenge of integrating EMR [electronic medical record] systems alone, we felt that a multi-tenant solution that was resident in the cloud would be cost effective for providers,” said Hardy. “As a cloud service, we aggregate, manage, and secure the data for our clients. We use a combination of Hadoop and relational databases for our analytics platform and deliver reports that provide insights to our clients for their risk strategies and their healthcare quality and cost metrics.”
Hardy says the next phase of healthcare analytics will be in patient accounts and accountability management.
“While we want to provide analytics to assist doctors and other healthcare providers with their performance, we also know that more visibility of care and treatment for patients can further the objective of quality healthcare and also lower healthcare costs,” she said. “The studies already tell us that 80% of most patient outcomes are dependent on patient behaviors and whether patients are following the care and treatment regimens that their providers prescribe for them.”