Wednesday, April 16, 2014

Truven Health Welcomes Simpler Consulting

This week I welcomed Simpler Consulting to our company. This acquisition makes sense because Truven and Simpler will make a game-changing combination in the healthcare marketplace – driving growth and strengthening our ability to reduce the cost and improve the quality of healthcare. Our powerful analytic capabilities, in combination with Simpler’s consultative expertise and unique approach to operational improvement, will complement each other in the following ways:

  • Enable provision of end-to-end performance improvement services for both Truven and Simpler clients
  • Support further development of enterprise-wide engagement
  • Support international growth for both businesses
In addition to its healthcare practice, Simpler has a commercial division that provides performance improvement consulting services to a wide range of businesses in the U.S., Europe, and Asia. We expect this business to expand in the immediate future and over time will look for additional opportunities with both our Commercial and Government divisions.

The entire Simpler management team is remaining with the business under the leadership of CEO Marc Hafer. They bring with them vast experience of the Lean performance improvement process along with proprietary methodologies and tools that have been developed and successfully deployed over many years.

In the past year, our company has completed the last steps of the very complex process of standing up as an independent company. Now I look forward to a bright future where, with our new colleagues, we will be able to bring ever greater value to our customers.

Mike Boswood
President and CEO

Monday, April 14, 2014

Using Algorithms and Predictive Models to Find Abuse and Fraud

A critical success factor in any program integrity effort is applying the appropriate algorithms and predictive models in pre-payment and post-payment claims analysis environments. Truven Health Analytics has experience developing and cataloging hundreds of algorithms which have been used (and are currently used) in various state agency, federal agency, health plan and employer operations to detect abusive and fraudulent claims schemes. We have also seen predictive model intelligence growing in the marketplace, and we are helping payers improve their predictive models so that they more effectively fight fraud and identify high risk claims before the claims are paid. While these sophisticated approaches are implemented to find what we didn’t see before, we also see our clients achieving results every year with some of the tried and true detection algorithms. Each year our expert panel – a team that works with payers across the healthcare spectrum every day – selects a set of key algorithms. We just presented a webinar on the Key Algorithms for 2014, and the presentation included:

  •  A new approach to the overuse of modifiers. We focused on modifiers 22, 24, 57, 76, and 77.
  • The device malfunction algorithm which identifies claims where the reason for treatment or services rendered is due to a malfunctioning implanted device
  • Extended DME rental use
  • Over utilization of diabetic supplies
  • Critical care on date of discharge
  • Advanced life support (ALS) transportation without an inpatient stay
  • Hospital acquired conditions
  • Over utilization of lumbar MRIs
  • Lumbar MRI, post lumbar MRI, or CT
Some of these algorithms represent new schemes we are seeing, and some represent schemes that continue to produce analytic results that PI units and Special Investigation Units (SIUs) can take action on and make recoveries. Our team has produced the Key Algorithms list annually since 2003 to support the healthcare payer community that is dedicated to improving integrity and eliminating fraud, waste, and abuse in healthcare. If you would like more information on algorithms and predictive models, feel free to reach me at david.nelson@truvenhealth.com.

David Nelson
Vice President, Market Planning & Strategy

Wednesday, April 9, 2014

Reducing Readmissions Must be Addressed Across the Care Continuum

A lot of attention has been given to hospital readmissions in recent years, and the establishment of a readmission outcome measure by the Centers for Medicare & Medicaid Services (CMS) in value based purchasing has incentivized hospitals to work diligently on the problem. The recent article in Kaiser Health News about Beth Israel Deaconess highlights the challenges and obstacles we must overcame to reduce readmissions. The reasons to address this issue go beyond the cost of it. One reason alone should be to improve the overall quality by preventing the re-exposure of a patient to the hospital environment where they can be subject to hospital-acquired infections and other safety concerns, such as falls.

For some of the top readmission diagnosis like Heart Failure and Pneumonia, the biggest obstacles to reducing readmissions have been not what goes on in the hospital, but what occurs when the patient is discharged. It really involves more about the psychosocial aspect of healthcare than the science of the disease and treating it. When the patient is discharged after a heart failure exacerbation, the medical component is typically stabilized. The failures often occur in the process, communication, and overall care coordination. 
  • Was the follow-up outpatient procedure scheduled before discharge?
  • Is a family member or caregiver aware of the follow-up appointment?
  • Can the family member or caregiver drive the patient to the follow-up appointment? 
  • Did the patient receive the proper diet instructions before discharge?
  • Do they have the resources at home to help comply with the dietary guidelines?
  • Can the patient afford the prescribed medications, and does the patient understand the instructions for taking their medications?
  • If the patient needs outpatient intravenous antibiotics, were home health services arranged? 
These are some of the questions that must be asked in order to reduce the risk of readmission.

Hospital systems and hospitals that have been successful in reducing readmissions have ensured a coordinated team of visiting nurses, social workers, pharmacist, and case workers all work together to coordinate the process, education, follow-up visits, and overall answers to questions that may come up to family and patients. The future of our healthcare system  will be tied to coordinating care using an overall population health analytics system that not only tracts information across inpatient and outpatient settings, but also enables all care providers to communicate more effectively, tying in real time surveillance, monitoring, and alerts. Therefore no matter where the patient is along the continuum (inpatient, outpatient, emergency department, or home) and whoever is interacting with the patient, information is constantly brought together and communicated to improve the health of the patient and reduce risk of readmission for high risk patients and chronic disease.

Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader

Tuesday, April 8, 2014

Price Transparency for Medicare Services and Procedures Can Help Avoid Wasteful Spending

I welcome the recent announcement from Centers for Medicare & Medicaid Services (CMS) that it is publicly releasing extensive data detailing how much Medicare part B pays physicians for more than 6000 services and procedures. I don’t share the American Medical Association’s position that this data release will be harmful. Medicare part B pays in excess of $77 billion annually for physician services, and the public should be able to see how those dollars are spent.

Truven Health research proves there is tremendous variation in price for hospital services and procedures, and I fully expect these new data will show the same level of price variation. I expect to see considerable variation in price for physician services (office visits, consultations, etc.), but I suspect the real story will be in the prices charged for procedures rather than just the physician services.
  • How much price variation is present for frequently performed services like EKGs and blood tests? I recently received a bill for a “Metabolic Panel Comprehensive.” The test costs pennies to run—and the bill was $145! In total, my lab bill was $1035.
  • Many physicians have invested in office testing equipment and can charge a wide range of prices for these tests. Bone densitometry equipment a good example: it’s marketed with a definite business plan. Doctors are told how many tests they need to do every month to pay for the equipment and guarantee a certain profit level.
Over the past months, several Truven Health articles and studies have highlighted the huge variation in prices for colonoscopies, a recommended screening test, ranging from several hundred dollars to thousands. The public has a right to see these prices before agreeing to the tests. That is the goal of the Truven Health Treatment Cost Calculator. Patients using this tool can see the actual charge for a given test in his or her community, compare costs and then make an informed decision. Our fee-for-service payment system drives wasteful spending on medical procedures, and full transparency is one way to better understand what is driving these high costs.

Michael L. Taylor, MD, FACP
Chief Medical Officer

Monday, April 7, 2014

Compound Drugs – What Can You Do About Their Startling Rise?

While many plan sponsors are paying close attention to their specialty pharmacy costs, they may be unaware of the latest disturbing trend in the pharmacy landscape:  the startling rise in the cost of compound drugs. Compound drugs are mixed at the pharmacy according to a recipe prescribed by a physician and, up until the last couple of years, typically cost less than $100 per prescription.

However, today, a new type of pharmacy – one devoted to compounding drugs – is springing up across the country. And with the surge of these new pharmacies, we’re seeing big increases in the billed charge of compound drugs, which are frequently for topical pain relief. Some pharmacies are now billing in excess of $10,000 per prescription for compound drugs, but a review of the recipe shows they are often using generic ingredients and/or ingredients not approved by the FDA for the conditions they are intended to treat. In addition, the FDA doesn’t monitor operations at compounding pharmacies to ensure safety and sterility of the products manufactured.

One employer recently learned it had paid almost $400,000 for about 140 compound drug prescriptions. The compound drugs were excluded from the pharmacy benefit manager’s (PBM) annual trend report, which caused the employer to question why the trend report didn’t reconcile with the PBM’s invoices. After adding in the compound drugs, the employer’s overall trend jumped from 11% to 18% for 2013.

PBMs apply varying degrees of review on compound drug claims, making these claims ripe for fraud, waste, and abuse, especially since it’s not illegal for a physician to hold up to 40% ownership interest in the compounding pharmacies to which they’re sending the prescriptions.

So what can you, as a plan sponsor, do about this? Start by looking at your data or asking your PBM about your compound drug claims costs. Second, talk with your PBM about their protocols – current and planned – to manage these unique claims. Third, ask your Truven Health account team how our Pharmacy Benefit specialists can help you determine the best protocols for your organization.

Marie Bowker
Senior Director, Practice Leadership

Oncology Treatments and Care Benefit from Big Data

An article in HealthCare IT News on March 21 discusses the latest use of IBM’s Watson computer for tackling the synthesis of complex information required to personalize cancer treatments to individual patients.   Drawing upon the medical literature, drug databases and patient genomic data, Watson will identify possible treatments for specific patients – tailored to their own genetic mutations. The application of Watson’s brain power to cull through an enormous amount of information is truly a step forward in the world of fighting cancer. The human brain can only synthesize small amounts of data at any given time, so having a computer help with the sifting and sorting is of tremendous value.

And so far, the reaction appears appropriately modest. Watson may be able to detect and identify, but Watson can’t interpret and place treatments into context the way doctors can. Watson is an aide that will hopefully free up human time for the things that human’s do best, such as interpret, understand, recommend, listen to and take into account patient emotions and family needs.

At Truven Health, our approach to big data is much the same. We use technology to simplify, organize and identify patterns of care, drivers of cost, or patient sub-groups. We draw upon many components of big data, from medical claims to hospital discharges, work productivity and oncology EMRs as well as the literature, to identify patient-level value in cancer treatments. And like our medical counterparts, we leave the heavy thinking, the place where intuition drives solutions and identifies new paths forward, to our researchers. Good technology in the hands of humans striving to treat and cure cancer is good for everyone!

Kathleen Foley
Senior Director, Strategic Consulting (Life Sciences)

Monday, March 24, 2014

Big Data and Analytics: Getting Past the Hype to Real Value

As a health plan in today’s complex and challenging environment, it’s easy to get your head turned by promises of Big Data and new analytic techniques. After all, you’re facing an immediate need for information and analyses to successfully manage your business. Big Data must be the answer, right?

 The best answer is “maybe.” The new data sources and analytic techniques just might hold the answers you’ve been looking for. Then again, the answers you need might have been right in your backyard all along. The question is, How do you get past the “Big Data hype” to find the sound data sources and smart analytic methods that will help you meet your goals?

The bottom line is that unless you know how these new tools and techniques can help you make better decisions, they won’t be useful to you. Before you jump to the “next big thing,” be sure you’ve fully explored the value in the data you already have.

“Next Generation” healthcare analytics can help you make better decisions — but only if the new tools, techniques, and science are combined with good data and a deep understanding of the business environment. Properly leveraged, the most promising analytics will help you respond to today’s rapidly changing business environment and enable you to thrive under reform, control costs, engage your consumers, and make the best or your new provider relationships. Intelligent application is what matters.

Read our latest insights brief, Next Generation Analytics: Getting Past the Hype and Finding Real Value, for more details. Or email us to find out how we can help you meet your business challenges with smart data and analytics.

Anita Nair-Hartman, Vice President of Market Planning and Strategy
Anne Fischer, Director of Healthcare Analytics

Wednesday, March 19, 2014

Health Information Exchanges Provide Valuable Information to ED Physicians

If you polled every physician, especially emergency medicine physicians, in the country, and asked if it would be valuable to have access to patient data from Health Information Exchanges to help prevent unnecessary admissions from the Emergency Department (ED); the answer would be 100% yes. I applaud the study by Joshua Vest PhD at the Weill Cornell Medical College to continue the national debate and increase the awareness about the importance of health information exchanges to reduce costs and unnecessary care in the country. The state of New York and others have been on the forefront to invest in the exchanges.

I realize that many are afraid to allow access to health records across a large spectrum because of HIPAA concerns, but I can tell you that as an emergency medicine physician, it’s safer for the patient. Emergency medicine physicians are the gate keepers and the ultimate patient advocate. If you become a patient in the emergency department, your physician will need to access records and diagnostic test results to avoid performing repeat tests and creating unnecessary readmissions. Many times a patient cannot remember what was done, where it was done, or even the results of the test performed. Yet, the patient is brought to a hospital in the middle of the night by ambulance to a hospital in town they have not been to. Yet, they had a vital piece of information during another stay that could mean the difference in whether additional test or admissions are performed. Even in the age of electronic medical records and advanced technology, it’s still challenging to try to get information from an unaffiliated hospital, clinic, or doctor’s office.

I actually worked a 12-hour shift in the Emergency Department just last week. I saw a patient who suffered an injury but went to an Urgent Care facility just a few hours prior to seeing me in the Emergency Department. The patient had an x-ray at the unaffiliated clinic, and therefore I didn’t have access to this information. It was a diagnostic test I needed to visualize to make the correct treatment and disposition decision. Fortunately, the urgent care clinic made a copy of the x-ray on disc and gave it to the patient. Thankfully, he brought it with him, preventing me from ordering another x-ray, adding to the cost of his treatment, and exposing him to additional radiation exposure. I was lucky in this scenario, but countless physicians (me included) could tell you stories where if we had access to information quickly, we could not only reduce cost, but improve customer service to the patient. 

We must continue to educate and support the need to Health Information Exchanges to improve safety, reduce cost, and improve efficiency. This further buoys the conversation about Population Health and the continued need for integration of clinical and administrative data on a real time basis.

Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader

Wednesday, March 12, 2014

Are Your Employees Getting the Benefits You Think You’re Providing?

Despite the Patient Protection and Affordable Care Act (PPACA) mandate of 100%, pre-deductible coverage for many preventive services, your health plan or Pharmacy Benefit Manager (PBM) may be interpreting or implementing the plan differently. Or, you may think your plan is not paying for services like cosmetic procedures or non-emergency use of emergency departments; but it depends on your health plan’s system setup.

Either way, if your employees aren’t getting the benefits they were promised at enrollment, it can cause major problems for you.

Luckily, there is a solution — a comprehensive audit of 100% of your claims.

From our experience at Truven Health Analytics™, a comprehensive claims audit typically reveals that up to 8% of claims are paid incorrectly. These incorrect payments often point to breakdowns in plan implementation, but they can also crop up if there are other issues like:
  • coding errors
  • lack of quality control
  • administrator system setup issues
  • even, fraud and abuse
Truthfully, if you have any question about how your carrier is administering your plan, a comprehensive audit of 100% of claims is in order. How else will you know how your plan is being administered?

Putting your health claims under the microscope and really analyzing them is the only way you can be sure you are maximizing the financial performance of your healthcare benefit and providing all of the employee benefits you contracted to provide. Plus, ensuring your claims are paid accurately — and in compliance with your plan design — could save you millions of dollars.

Plan sponsors can read our latest insights brief, Three Reasons Your Employees Aren’t Getting the Benefits You Think You’re Providing, to get details about what to look for and how we can help.

Marie Bowker
Senior Director, Practice Leadership

Monday, March 10, 2014

Maternity Care the Ideal Setting for Evidence-Based Practice and PCP/Specialty Collaboration

The recent Crain’s New York Business article “Birthing biz booms for hospitals,” captures the complex dynamic of balancing hospital service lines to support revenue, manage costs, and ensure the well-being of a community – in this case mothers and babies. Successfully managing these three objectives requires strong leadership and evolving business intelligence resources. As negotiated reimbursement rates shift from volume to value, it won’t be enough to merely focus on high-margin procedures. 

The best hospitals and health systems recognize the importance of integrating clinical pathways that invite evidence-based practice from both primary care and specialty providers. Maternity care is an ideal setting for such collaboration, since the stakes are so high. Rapid identification of high-risk mothers can not only ensure the health of the mother, but also the well-being of the newborn, with a reduced likelihood of needing to use neonatal intensive care resources.

Effective care coordination for any service line depends on timely, accurate and actionable data across the care continuum. Accomplished leaders leverage such intelligence to identify gaps in care, quality below expectations and costs attributable to inefficiencies. As negotiated reimbursement rates shrink, penalties for avoidable events expand and transparency to consumers evolves, healthcare data will be the medium by which we not just measure our achievements, but ensure the health and well-being of our collective mothers, babies, and families.

Michael R. Udwin, MD, FACOG
National Medical Director