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Better Care @ Lower Costs |
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Better Care @ Lower Costs |
| We have two ways of quantifying healthcare outcomes‒Combining both cost and quality into a single dollar value.
When you can quantify healthcare outcomes there are all kinds of things that you can do that you couldn't do before to drive down your healthcare costs while improving the quality of care. This Power of Quantifying Outcomes video answers your question‒“So what?” |
A “good outcome” for an employer is the employee at work. Our “Claims + Absence Costs” solution accumulates all the costs, the medical and pharmacy claims, and the medically-related absence costs, to get the employee back to work and keep them there. This solution measures cost via the claims and absence dollars, and quality via the absence costs, which straddle both cost and quality. Not only are the absence costs a real cost to an employer, but they are also an indication of the effectiveness of the care. The quicker the employee got better and returned to work, the more effective the care was. The Claims + Absence Costs solution is for employers that self-insure their health plans and workers’ compensation programs (including non-subscribing employers in Texas that opt out of workers’ compensation insurance and adopt an injury benefit plan), as well as workers’ compensation insurers and TPAs, who can substitute the lost wage indemnity payments to the injured employees for the absence costs.
When we have just the claims, we calculate the claims per healthy day. Instead of asking how much it costs, and how long it takes, to get an employee better and back to work, we ask how much it costs in claims per day to keep someone healthy. This solution measures cost via the claims, and quality via the number of healthy days. Healthy days are the 365 days in a year less the number of “unhealthy” days, which our algorithms can derive from the claims. Unhealthy days are days spent in the healthcare system (hospital stays, doctor visits, etc.) or at home, but unable to function normally. The Claims per Healthy Day solution is for health insurance companies and TPAs, Medicare Advantage plans, state and other multi-employer health plans, ACOs and provider groups taking on risk, and when measuring the outcomes of the dependents under an employer health plan.
| In addition to our Claims + Absence Costs solution, in the workers’ comp space IntegerHealth was a member of Guidewire’s two-year Insurtech Vanguards program (2022-2023) and is a Strategic Alliance Partner with ODG. |
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Guidewire is a NYSE P&C insurtech with more than 450 insurer clients. Through its Insurtech Vanguards program, Guidewire identifies and highlights the top insurtech companies bringing novel solutions to the P&C industry and connects them with those insurers. |
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ODG (Official Disability Guidelines), part of the Hearst Health Network, is a nation-wide database of non-occupational disability and workers’ comp injuries. IntegerHealth is a Strategic Alliance Partner with ODG, and integrates extensively with it for benchmarking, best practices and predictive analytics. |
Health plan and workers’ comp data are kept in separate silos. When we have both, we combine them and gain insights that can’t be gleaned from just one or the other. Health plan data contains employee comorbidities that workers’ comp data often doesn’t. When an employee has a comorbidity, especially a behavioral health issue, the workers’ comp medical claims and time off increase significantly.
Our health plan and workers’ compensation platforms double as data warehouses. Not only do we provide our one-of-a-kind outcome analytics through them, but our “Guided Analytics” stitch the data into a story that tells you not only what happened, but why?
Every employer has wellness programs. They know what they pay for them. They have no idea what they get in return. The vendors have promised fantastic results based on qualitative measures that the vendors themselves select and report, such as the steps taken in a walking program or the decrease in A1c scores in a diabetes program. At best these are mere proxies for what really matters.
What is the purpose of a wellness program? To make the employees healthier because healthy employees consume less healthcare and miss less work. That’s what we quantify. How much did the medical and pharmacy claims decrease for the employees participating in the program? How much did their absences related to those claims go down? From that we calculate the program’s actual ROI (Return on Investment). Anything else is just fluff.
Our algorithms also identify individuals enrolled in a program who are not participating in it, individuals not enrolled in a program who would benefit from it, and programs that an employer doesn’t have that it should.
We distill our outcome analytics that merge cost and quality into a single number…QScore.
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For each diagnosis and/or procedure (e.g., diabetes, knee surgery, etc.) we assign a QScore to each physician, health system, or other provider based on the outcomes that they have achieved when treating that diagnosis or performing that procedure. The higher the QScore, the better the results realized. |
We provide our analytics to clients through a powerful internet portal consisting of interactive dashboards and reports. We can also provide streamlined portals listing the best doctors by diagnosis (and in some cases, treatment patterns) to: (1) case managers handling high cost and chronically ill patients, (2) workers’ compensation adjusters directing the care of injured employees, (3) physicians referring patients to specialists and surgeons (including PCPs staffing employer clinics), and (4) patients.
There are several unique and critical aspects to our algorithms:
Root Diagnosis. Our proprietary algorithms and groupers identify the root diagnosis with respect to a set of claims and then group together all the claims (and absence costs) related to it. Our solutions then calculate the outcomes on a diagnosis-by-diagnosis basis.
Risk Scoring. We risk adjust all the data. If you ask any doctor why their costs are more than another doctor’s, they’ll always give the same answer. “Because my patients are sicker.” And sometimes they’re right. Sicker patients cost more, and take longer to get better. If you have two patients with the same back injury, one of them young and otherwise healthy, while the other older, overweight and diabetic, the older patient is going to cost more and take longer to recover. So we adjust for comorbidities by assigning each patient a risk score. That way our rankings are based solely on performances, not the particular circumstances of the patients treated.
Allocating Costs. When allocating costs to a physician we include all the costs for which they are responsible‒both their direct costs and the indirect costs from their downstream referrals. If a doctor sees a patient once and then refers them to a surgeon, that doctor’s direct costs will be low compared to another doctor that works with the patient to avoid surgery. However, the first doctor’s overall costs‒direct + indirect‒will likely be much higher. This allows us to evaluate a physician’s referral patterns, and suggest changes when appropriate.
Sorting. We sort providers into categories, because you can’t compare a PCP to a surgeon; and we can sort by geography and other parameters too.
We take three to five years of past data from a prospective client and model it to show them with their own data how much we could save and improve care. If after that demonstration we move forward, we then have a head start and hit the ground running on Day 1, refreshing the data on a monthly or quarterly basis.
We take the claims and absence data in encrypted feeds over our secure FTP site, and everything is fully HIPAA and SOC compliant. As discussed above, in the beginning we take three to five years of historical data, which enables us to deliver robust results on Day 1. After that, we take monthly or quarterly updates.
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