Making the most of health care claims data in value-based care

Carl Johnson In my last blog post, I wrote about the need for using clinical data to create a comprehensive data set for analytics. The other side of that equation, however, is using claims data effectively.

Providers already can more easily leverage claims data than clinical because of stronger reporting tools and standards, but there are some areas for improvement.

  • Providers, especially those working on risk-based contracts, should ensure they receive all outbound claims as well as adjudicated claims for their patients. These offer a more complete picture of the patient’s health. For example, this could help a primary provider recognize if a patient is receiving care from an outside oncologist.
  • Claims can take weeks or months to process, so they don’t work well for current treatment plans. But they can provide a predictive model for future care, costs and risk. When combined with clinical data, they can demonstrate the success of a treatment plan by providing historical intervention measures.
  • Providers can identify redundant or overused services with claims data, allowing them to adapt treatment plans and reduce patient costs.

As the health care economy evolves, providers will need to shoulder more of the risk analysis, a task traditionally handled primarily by payers. Successfully doing so will help ensure financial stability for a provider.

In handling patient risk, providers have two natural advantages: direct relationships with patients and the detailed clinical data in the EHR. But if providers are to succeed at financial management, they can’t afford to ignore the claims data that payers have used, nor the analytic methods the payer community has developed. By themselves, neither clinical nor claims data provide a complete picture. It’s the combination that’s so powerful.

For a full report on the benefits of combining clinical and claims data, read the latest Optum featured topic: The importance of clinical and claims data.

–Carl Johnson, MD, EdM, MSc.

About the Author:

Carl Johnson, MD, EdM, MSc. is a pediatrician trained at Boston Children’s Hospital. He completed a Medical Education fellowship at Harvard Medical School and was a faculty health services researcher at The Mount Sinai School of Medicine.

Before joining Optum Analytics he worked as a physician executive at Cerner Corporation. He is a graduate of the Mount Sinai School of Medicine in New York City and has held faculty positions at Harvard Medical School, University of California at San Francisco, The Ohio State University, and The Mount Sinai School of Medicine.

Dr. Johnson believes that healthcare can be transformed with the help of the right data. When he is not helping to transform healthcare, he can be found playing tennis, cooking, perfecting his French, taking photographs, reading historical fiction, listening to music, and watching Ohio State Football.

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