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How to Shift to Value-Based Healthcare and Improve Payment Integrity Using AI and Analytics

How to Shift to Value-Based Healthcare and Improve Payment Integrity Using AI and Analytics

Data-driven Insights are Transforming the Healthcare System

Spending on healthcare in the U.S. has been rising steadily for years. In 2021 it reached $4.3 trillion with health spending accounting for nearly one-fifth of GDP. In the traditional service-based healthcare model, higher costs do not necessarily mean better care or clinical outcomes. Providers are paid for the services they provide, and, unlike value-based care, patient outcomes are not necessarily part of that equation.

What’s more, 80% of medical bills are estimated to contain errors of one kind or another. These inaccuracies lead to inefficient systems in which overpayment is rife and which ultimately contribute to higher costs for the patient. Ensuring health plans and providers are billed and paid accurately – also known as payment integrity – relies on improved data analytics to identify mistakes, duplications, and potential cost savings.

Similarly, patient data and advanced analytics play a pivotal role in helping providers transition to value-based care in which they are paid on outcomes rather than services alone. One example of this would be incentivizing providers to manage chronic conditions more effectively, keeping the patients healthier, and freeing up resources – physicians, hospital beds, and so on. While value-based care is the gold standard to which providers aspire, it can be difficult, as a provider, to assess performance against a value-based care agreement without access to critical cost data analysis.

Clinical Insights and Cost Analysis with Patient 360

Transitioning to a more transparent, efficient, value-based model of care requires a modern approach to data transformation and analysis. Solutions like the Patient 360 healthcare framework powered by Apexon’s Healthcare Data Analytics Platform consolidate patient, cost, and billing data from across the entire healthcare delivery system into one unified view. Providers can easily access and review contracts, addendums, and price files, extracting the relevant criteria, such as parameters, penalties, commitments, or incentives. Insights can be customized according to the provider’s specifications per member per month (PMPM) and/or per member per year (PMPY).

Contracts, Care, and Compliance

Another important capability that providers need in order to shift towards value-based care is to compare the contract against the invoices and what stakeholders do. Ordinarily, this is a painstaking process of matching words and invoices in Excel to the specifics of a contract. Advanced, automated analytics tools in the Patient 360 framework identify anomalies fast as well as highlight any compliance issues.

However, any data analytics solution designed to improve payment integrity needs to be capable of looking at all healthcare provisions, including off-contract ones. These have a significant financial impact on care providers, and yet many providers cannot easily quantify these costs. Patient 360’s optimization and utilization capabilities enable providers to spot these real trends based on usage, whether contract-based or pay-as-you-go.

Enabling Agility with Advanced Analytics

Similarly, understanding utilization is key to informing contract negotiations. The standard twelve-month view (or PMPY) is a useful guide, but often what’s more illuminating is examining the last one to three months’ worth of invoices. Patient 360 enables providers a granular, consolidated view of patient data that provides insights not only into the past but into likely outcomes in the future. To paraphrase the hockey legend Wayne Gretzky, analytics helps providers maneuver to “where the puck is going, not where it is now.”

Providers can realize changes in their value-based care agreements within weeks or months of using a data analytics framework like Patient 360. Healthcare provision analysis is not just useful for contract negotiations, it also helps to shed light on an individual’s likely clinical trajectory. For example, the provision history of a patient suffering from PTSD or substance abuse can be changed quickly – the most recent month may bear little resemblance to the previous three or four. Understanding these utilization changes can help providers realize if patients have recently changed treatment protocols, and the subsequent health impact of those changes, as well as understand the impact on the contract.

How Patient 360 Optimizes Patient-Provider Engagement

The Patient 360 solution combines Apexon’s data engineering expertise with AWS tools for cloud-native development and implementation. Health companies typically begin by storing patient information in Amazon S3. Using Python, Apexon works with providers to review billing and other financial documentation for the relevant parameters. The deep data analysis then takes place in the healthcare provider’s domain using Amazon EMR which provides unprecedented granularity.

One example of this would assess and incorporating contract reviews. The traditional approach would be to run to the end of the agreement and then examine the appendix and costs. Using Amazon EMR and Patient 360, providers can remain reactive with detailed progress reports on contract reviews, an important advantage given the significant proportion of contract clauses referring to a healthcare provider’s financial obligations.

Solutions that can drill down to provide insights on frontline users, like Patient 360, are important in improving patient experience and engagement. Using Patient 360, providers can easily and quickly benchmark their performance on a contract. The provider would first leverage AWS Quicksight to look more closely at the agreement between the payer and the provider before then drawing up a shortlist of options comparing and contrasting potential cost savings for the patient. Using Amazon SageMaker, Amazon S3, and Amazon Athena, and moving to Amazon HealthLake, the Patient 360 framework allows providers to create a tailored strategy to improve patient engagement. For example, taken together these tools can help providers add significant value to patients by sharing insights and a walkthrough of cost-saving options.

Furthermore, Patient 360 uses tracking, measurement, and visualization tools to help providers understand the savings, utilization, and opportunities on an ongoing basis.

Architecting a New Era of Healthcare

Realizing cost savings in the healthcare system is of interest to both providers and patients. Until recently, legacy systems and technical difficulties have traditionally prevented the healthcare ecosystem from identifying and realizing cost-saving measures. Now, thanks to cloud, advanced analytics and AI/ML, among other factors, healthcare technology is at an inflection point. Healthcare companies find themselves finally able to overcome the systemic and technical barriers thanks to high-tech innovations and strategic partnerships. Companies like AWS and Apexon can now leverage high-speed, cloud-based, big data analytics to enable healthcare providers analyze patient data to transformational effect. An enabler of value-based healthcare, the Patient 360 framework is designed to serve all stakeholders on an equal basis.

Looking ahead, Apexon and AWS’ long-term partnership is a commitment to improve the health of health plan members and make healthcare more affordable. Together, Apexon and AWS engineers have designed an architecture that combines Apexon’s Healthcare Data Analytics Platform with the AWS FHIR and HIPAA-compliant cloud offering and the AWS security operating center. The resulting solution, Patient 360 ensures that healthcare providers’ data handling is of the highest integrity while simultaneously offering interconnects via APIs that allow them to develop custom services that improve outcomes and engagement.

Apexon and AWS have partnered to create a powerful set of tools that healthcare organizations can use to harness disparate data and create an all-round view of the patient. Through their joint solution, Patient 360, healthcare companies can turn data-driven insights into actions that improve the efficiency of the entire system: from timely health interventions, to cost savings, to contract handling. To find out more about how Apexon’s is humanizing patient care, take a look at this fact sheet.

The topic was originally discussed in an HIMSSCast podcast episode titled “Patient Data and Insights Enable Value-based Care and Improve Payment Integrity.”

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