Intro of Data Analysis in Healthcare for Triple Aim

Have you ever heard of Triple Aim in healthcare? If not, you may notice that private and public entities around the world are investigating how to maximize the power of analytics to improve quality of care, operational efficiencies, billing reimbursements with a lower cost. United States spent about 17.9% of GDP on healthcare in 2011, according to World Health Organization’s report.

With such a great opportunity, millions and millions of healthcare data are waiting for analysts to be turned into useful insights and predictions for Triple Aim. This presentation paints a big picture of what you can do with these huge volume and complicated data. What can be turned into reports, predictions, and actions? Analysis of enrollment and emergency department (ED) visits demonstrate the aspects you can dig into.

Moreover, what is the structure for claims? How to use quality measures? You may get a peek from an example of ED visits about how to dig out ED visits from claims.

Lastly, it explains common medical billing and coding, including ICD, CPT, and HCPCS to help you get a good grasp of these coding standards.

Quality Measures in Healthcare

What is high quality health care? The answer can be “doing the right thing, at the right time, in the right way – and having the best possible results”. It is often measured in terms of cost, quality, and access as the so-called Iron Triangle of Health Care. Many healthcare programs have been set up to reward the quality of healthcare services, and to help consumers and payers make decision for the best use of their healthcare dollars. Today I would like to give a brief introduction about two common quality measures in healthcare that I learned through my work. One is HEDIS (Healthcare Effectiveness Data and Information Set) measures and the other is Physician Quality Reporting System (PQRS) . These are two main measures used for quality reporting.

HEDIS measures

HEDIS measures are developed, managed, and updated annually by the National Committee for Quality Assurance (NCQA). (NCQA is often referred as the “gold standard” in health plan accreditations. NCQA accredited health plans covers about 70.5% of all Americans enrolled in private health insurance according to NCQA’s own report.)

HEDIS measures address two types of care: preventive health care (children and adolescents, women and adolescent girls, adults, and seniors) and condition-specific care. Condition-specific care can be both chronic conditions and acute conditions. Sometimes HEDIS measures are categorized as chart review measures and claim-derived measures.

Patient-Centered Medical Home (PCMH)

NCQA provides PCMH program with the mission of improving the quality of healthcare. It includes clinical programs such as:

– Diabetes Recognition Program (DRP)

– Heart/Stroke Recognition Program (HSRP)

– Back Pain Recognition Program (BPRP)

Therefore, PCMH quality measures utilize the HEDIS measure set.

Examples of HEDIS measures

Johns Hopkins Medicine’s HEDIS tip sheet of September 2013 demonstrates how HEDIS measures are used by providers. You can see that CPT, ICD-9 codes, and UB Revenue Codes are used for billing purposes.

PQRS measures

On the other hand, Medicare has developed PQRS for its specially covered populations: primarily elder people over the age of 65 or younger with chronic disabilities. You can learn more detailed about PQRS from CMS here.