This autumn, in the process of preparing our November-December cover story on the collaboration on the part of health plans and provider organizations in leveraging data and analytics for population health and clinical transformation, Healthcare Innovation Editor-in-Chief Mark Hagland interviewed nationwide leaders from both the payer and provider segments in U.S. healthcare.
Among those he interviewed was Antonio Linares, M.D., regional vice president and medical director for Anthem National Accounts, a division of the Indianapolis-based Anthem. Dr. Linares is a nationally recognized health plan leader, who has spoken widely in conferences such as the HIMSS Annual Conference, and at Healthcare Innovation Summits sponsored by Healthcare Innovation. Below are excerpts from the longer interview that Dr. Linares gave to Hagland earlier this autumn, on this important subject.
Can you tell me how you see the landscape around leveraging data analytics for population health, right now?
Let’s define population health: our definition is a model that we call Total Health, Total You (THTY). And by total health, we mean that all the data and information available in the healthcare ecosystem should be put into a personalized profile. We’re focused on a digital and analytics first approach. Within THTY, there are several high-level goals: first, to increase member and patient engagement through smarter tools that empower people to engage with their health. They are powered by activation tools that use the knowledge we have about the member including in-depth risk scores, and that’s where the analytics comes into play. The second high-level goal is to provide a better consumer experience of healthcare. And to achieve that, we have more clinically focused advocacy and care navigation models, that boils down to better care coordination. The third area is really the physician and clinical partnerships and collaborations. And that’s where our advanced analytics help to improve care delivery, and what we call care optimization.
By using data, we are able to assist in forging these connections so care can be connected to the different care providers an individual may see, giving a total picture of the person. In that regard, we’re looking at provider collaboration and care optimization as key areas where we can focus and make an impact. We’ve also identified that about 45 percent of healthcare waste arises out of variation in care quality, where there’s inconsistent application of care guidelines. We’re targeting that in our analytics, by improving care-gap analysis through what we call “hot-spotter reports.” With a hot-spotter report, we can identify in advance individuals who are likely to use the ED inappropriately or to not adhere to evidence-based guidelines, and we can then alert the doctors or care team.
In that, we look at three areas. How can we achieve greater effectiveness of care delivery? When you wrote about the JAMA study of waste in the healthcare delivery system, you noted that the authors had outlined six domains that account for most of the excess waste in healthcare. In our care optimization model, we’re targeting “failure of care delivery”; “lack of care coordination”; and “overtreatment of low-value care.”
We’re looking at provider collaboration and care optimization as key areas where we can focus and make an impact. We’ve also identified that about 45 percent of healthcare waste arises out of variation in care quality, where there’s inconsistent application of care guidelines. We’re targeting that in our analytics, by improving care-gap analysis through what we call “hot-spotter reports.” With a hot-spotter report, we can identify in advance individuals who are likely to use the ER inappropriately or to not adhere to evidence-based guidelines, and we can then alert the doctors or care team.
Our analytics process can identify the three percent of their panel membership that is responsible for 29 percent of a physician’s panel’s healthcare costs. We’re able to give them that report, with actionable insights. The report can provide actionable insight around membership with poor diabetes compliance, asthma, or heart disease. This lets the care provider focus additional efforts on these are the individuals you need to needing additional support address. Using that data in one our western accountable care organizations (ACOs), we’ve been able to target members who have complex conditions and other situations, who need help and who would benefit from care coordination and disease management programs, at two times the level of accuracy, and are now able to create a future risk model that predicts 163 days in advance an individual who’s more likely to fall into one of those high-risk categories.
For example, one provider in Fort Collins, Colorado, Dr. James Kesler, a family physician, by having these types of actionable insights, he was able to improve his practice. Here’s what he said about Anthem’s data analytics and consultation support: “It gave us a vehicle to actually practice the type of medicine that we see makes a difference.” From that perspective, we want the data and information to be able to be implemented and used within a practice’s workflow. The data we are moving is aimed at helping lower the administrative burden and improve the workflow of the doctor, so that it doesn’t add to the burdens of the physicians. And it’s team-based, so that any member of the care team can take action.
How is this data sent to the participating physicians?
We’ve implemented near-real-time support. We provide a portal accessible 24/7, with data refreshed continually, and it’s accessible to the entire team.
What have been the biggest challenges and successes in this approach?
The biggest challenges: looking at data across systems—we have to aggregate information from all sources and it all has to be connected. We’ve been able to create powerful and insightful analytics, across four domains. The first domain is the claims-based data—medical, pharmacy, and labs. The second is the demographics of the member population. The third domain is the specific medical-diagnostic data. We have nearly 80 million data sets for members and patients, that power the analytics. And the fourth is utilization data.
And that’s where we’re finding more data, as we start to include information from EHRs, as well as publicly available social determinants of health data. And with data from those four domains, we come up with a higher predictive value, where we’re able to share that around that 3 percent of members are responsible for 29 percent of healthcare costs.
Using this, we are two times more likely to be able to target members who have complex conditions and other situations, who would benefit from care coordination and disease management programs. And, using those four domains, we’ve identified that we can create a model that predicts 163 days in advance an individual who’s more likely to fall into one of those high risk categories.
And 163 days is amazing.
Yes. Again, that’s the fine-tuning of creating a model with analytics. And with diabetes, asthma, and heart disease, we’re able to identify 45 percent of new cases early. For example, we can engage patients with diabetes early, after getting their first prescriptions. And we’ve found that this particular approach, compared to other types of offerings in the market, has a 7-10 percent higher predictive value. And all of this is very important for the timing of high cost case identification. About 18-20 percent of those who will incur $50,000-100,000 in health insurance claims per year, can be identified for case management early.
How do you see this landscape around all of this five years from now?
I see a very positive future. Number one, from the perspective of pay-for-value models, the majority of our provider payments are now are in a pay-for-value approach, and that’s only going to increase, and these tools are going to support that platform. In those three areas I told you about, we’re creating a mobile hub called Sydney, that creates a human-centered digital approach that is hyper-personal and increases transparency, and also allows providers to give patients easy online appointment scheduling, virtual visits, real-time online payment, and coordination of visits with specialists. And this is the beginning of that five-year window, using a mobile hub that harmonizes all elements of the healthcare ecosystem for a better member experience, and so that the employer can provide a better on-boarding experience for their employees, and a better workflow experience and real time reimbursement for providers.
Additionally, we have a program called Live Health Online that uses the AmericanWell platform and provides 24/7 access for urgent, immediate calls, to providers, as well as appointments with psychiatrists and psychologists. The program has expanded to add emerging risks including hypertension control, weight management support, and also lactation support to improve child/maternity services. So telehealth is a big part of our future, and we’re looking at providing virtual care coordination with our care managers as well.
And we’re also rolling out a program called Concierge Cancer Care in 2020. I think it’s a glimpse into the future. Anyone newly diagnosed with cancer gets the delivery of a kit at home that allows them to do 24/7 self-monitoring and home assessment for things like fever, dehydration, heart rate, blood pressure, etc., and allows them to then contact a doctor via Live Health Online. The individual could receive advice directly or be given a virtual second opinion from one of the top cancer centers around the country. This is the future, where members can have 24/7 online decision support by a doctor, by a nurse, and access to world-renowned experts, for their specific condition. It is the first of its kind for health plan to roll out this level of specific care for cancer and we think it will mean better care for members.
