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How Equality Health uses predictive modeling to provide value-based care

Fitness & Health:

Equality Health, a Phoenix, Arizona-based health system focused on value-based care delivery, has significantly increased the number of value-based contracts and expanded its network of independent primary care providers since the company was founded in 2015.

THE PROBLEM

Today it has more than 25 VBCs and 5,000 independent primary care providers in its network. Managing, storing, analyzing and reporting the received data from all payers, along with supplemental data sources, presented a challenging problem for Equality Health to solve.

Examples of data received include member eligibility, pharmacy/medical claims, supplemental lab results, quality and hospitalization census. The VBCs span Medicaid, Medicare Advantage and Expansion lines of business.

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Payers have different adjudication systems, so even if they all followed standardized formats, the logic of processing the data is individualized and requires regular manual coding. In addition, mergers and acquisitions among health plans have impacted VBCs and associated data.

“Equality Health provides this summarized member healthcare data in a consolidated format to our network of providers, so they have a holistic view of the patient’s care,” said Todd Galloway, chief actuarial officer at Equality Health. “Providers typically only know the data related to the services or medications prescribed by their practices.

“This information enables the providers to create targeted treatment plans for patients, so they get the right care in the right setting at the right time – ultimately reducing cost and improving outcomes,” he continued. “We do this through our supplemental care management services and proprietary technology platform, CareEmpower.”

“The provider analytics department helps ensure the providers are keenly aware of actionable opportunities for them to maximize value.”

Todd Galloway, Equality Health

Providers’ administrative resources are limited, now more than ever because of the pandemic. To streamline efficiencies, Equality Health’s model helps providers quickly identify which high-needs patients require attention.

The quicker this important clinical information gets to providers, the sooner they can address their highest-need patients. This is important because 5% of any group in healthcare accounts for more than half of a group’s costs, he noted.

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PROPOSAL

“Daraja Services proposed informatics platforms including proprietary predictive modeling algorithms and analytical and statistical reporting supported by an analytical data warehouse,” Galloway said.

“In addition to Daraja Services’ actuarial expertise wrapped around all solutions, the group brought applied experience working with payers, providers and hospital groups.

“The predictive modeling examines claims and pharmacy information, social determinants of health, and cultural and environmental challenges to help identify who among Equality Health’s 350,000-plus members will be high-risk, who will require the most assistance in the next year, as well as their probability of hospitalization, rising risk or an emergency room visit,” he added.

The existing Daraja ADW architecture will simplify Equality Health’s complex payer and supplemental data sources into standardized formats to get real-time actionable information to providers, he explained.

“Data automation into the ADW will generate ROI by saving time manually processing data, increase data quality/consistency, and enhance business intelligence,” he said. “An additional layer of sophisticated reporting will empower our network providers to better serve their patients and accelerate value-based initiatives such as closing gaps of care and achieving quality improvement goals.

“The extra predictive reporting will help Equality Health and providers to better understand and interpret risks, find actionable opportunities, and gain a competitive advantage,” he continued. “Independent practice providers can continue to be independent with this information, see how their care patterns compare to peers, and understand how to mitigate challenges that will also increase their revenue – all while helping their patients.”

MEETING THE CHALLENGE

With the Daraja ADW solutions, Equality Health’s VBC data sets are mapped into the existing architecture along with additional business logic such as groupers, indicators, reference tables (ICD descriptors, NPPES, etc.) and member BI (risk adjusters, statistical predictive indicators, preventative flagging).

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The ADW then has code for data cubes to feed existing reporting suites for payer, provider and member analytics. The report suites include profit and loss, opportunity reports, scorecards, member/provider profiling, and outcome metric reports.

“The ADW is integrated into Equality Health’s supplemental care management services and proprietary technology platform, CareEmpower,” Galloway explained. “This integration efficiently displays patient data in the platform and allows providers to access information and prioritize highest-need patients.

“Then, providers can do a deep dive into individual patient profiles, which supplements and shares information related to the patient’s medical care along with other subjective-type information, such as their social determinants of health,” he continued. “Providers gain immediate access to specific, actionable steps that help keep patients healthy and avoid costly hospitalizations.”

In addition to the providers, the ADW and reporting will be used by or will impact other departments across the Equality Health enterprise. Providing this level of business intelligence across the organization helps with critical business decisions, and development of life-saving clinical programs – all of which support patients and value-based goals, he noted.

And the business intelligence gained from the technology will aid in payer partner discussions aimed at the shared goal of reduced costs.

“The desired outcomes depend on the stakeholders involved,” Galloway said. “Today, Equality Health’s actuarial and informatics division is structured to optimize the success for each major stakeholder – payers, independent primary care providers and members. The payer analytics department is tasked with ensuring all contracts are fair and actuarially sound.

“The provider analytics department helps ensure the providers are keenly aware of actionable opportunities for them to maximize value,” he continued. “The member analytics department is tasked with identifying and stratifying high-risk and rising-risk members for additional care opportunities.”

And the business intelligence department is responsible for the data architecture and coding required to support all company analytics, which requires a unique mix of technology and business knowledge to architect the datasets required for analytics.

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RESULTS

Three success metrics achieved since implementing the Daraja technology of ADW and reporting thus far include:

  • Reduced time of manual coding and monthly data processing
  • Reduced time of loading data into CareEmpower
  • Streamlined business intelligence for data-driven decisions

“Since the integration of Daraja technology, the number of team members and time required to manually code all 20-plus VBC data sets for monthly processing has been greatly reduced,” Galloway reported. “This administrative reduction is expected to continue.

“The new solution also had an impact on when the data is processed and loaded into CareEmpower,” he added. “Before the technology, data was processed after the latest payer data was received. Now the data will be processed as soon as it is received by the payers and the integration with CareEmpower will automatically load. This gets the necessary information to the providers to impact patient care even faster.”

ADVICE FOR OTHERS

Galloway’s advice to his peers? Think backwards.

“As the cliché suggests, you cannot manage what you don’t monitor,” he explained. “In value-based contracting, there are several factors and stakeholders to manage. Success starts with and is dependent upon properly organizing data.

“We take a unique approach to structuring data by thinking backwards and starting with the question, ‘What are the specific actions to improve outcomes?'” he continued. “From there, the team works backwards to determine the data needed to support the outcomes desired.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.


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