Health Plan Data Unlocks Population Health Improvements

By analyzing claims data, Milwaukee-based Children's Hospital has measurably increased immunization rates and boosted care delivery and outcomes for some of the city's most vulnerable citizens.

By harnessing the data available through its Children's Community Health Plan—Milwaukee-based Children's Hospital is able identify at-risk patients and to roll out and test new models of care delivery to targeted populations.

Owning and operating a health plan is a significant advantage for a health system when it comes to achieving population health goals, says Robert Duncan, executive vice president, community services, at Children's Hospital of Wisconsin.

"The real opportunity with the health plan is that it goes beyond what a normal health system can see from a data standpoint. It gives a more detailed picture of members' claims and data than can be seen in an electronic health record. The data is very important," he says.

Identifying Key Patient Subgroups
Children's Community Health Plans' data is used to focus on three important patient groups for population health management: Those who are sick but rarely seek care, those who also seek care from other providers, and those who are not seeking care at all.

For example, Duncan says, patients with chronic health issues who are not receiving regular care, can be located through the claims data and encouraged to seek treatment.

Population Health Really Does Work

"If two years ago, a plan member had a claim that shows they are diabetic and since that time they have not sought care, you can have a situation that from a population health standpoint you need to address. You need to see what is going on there and try to get that person into a preventive care program before they have a major episode," Duncan says.

Likewise, when patients receive care from other providers, health plan data can augment clinical information in the health system's EHR to give a more complete picture of their health status.

"We may have a child in the emergency department with asthma and through the health plan we can see that the child is also getting care at a local retail clinic or has been seen in another hospital's ED. If you just look at the electronic health record, you would see the child has not returned since their ED treatment and assume they must be doing well. The health plan data gives a different story," Duncan says.

Children's can also pinpoint plan members who are not seeking care at all, including wellness visits and preventive screenings, and reach out to them with targeted messaging, Duncan says. "This gives us an opportunity to manage populations in addressing those needs on the front end."

Tackling Population Health Goals
Along with aiding Children's with identifying these three subsets of patients, health plan data is also helping the system to achieve specific population health goals. In particular, Duncan says, the organization set out a few years ago to increase childhood immunization rates in its market.

"We decided that immunization is one of those things we wanted to tackle as a system. We used health plan data to find these kids and get them immunized whether or not it was in a traditional setting. We set up clinics in places where kids gather, such as schools, community centers, and churches. We had special clinics at the hospital," he says.

The results of Children's targeted efforts have been substantial, Duncan says. "What we saw was a significant increase in immunization rates for our city, and more importantly, our health plan member compliance rate is now the highest in our service area. It couldn't have happened without the utilization data."

Another important example of data being used to improve care delivery and outcomes is Children's partnership with the Wisconsin Department of Medicaid, through which the health system is providing services to children in foster care. The organization operates the state's largest foster care and adoption agencies.

"In the current structure, the data is compiled in three different departments at the state. With our partnership, now we are running everything through our health plan. Now with these children that we consider to be some of the most vulnerable kids out there, we are able to work with providers to develop and test models of comprehensive care organized around care coordination teams," Duncan says.

"In the past, the data was very fragmented, and we were not able to do this. Through this effort, children now have that care coordination team making sure they are getting the right care to improve their clinical and social outcomes."

Now in the third year of the partnership, Children's has the first-year data and is currently analyzing the second-year data to determine the results, which Duncan says look promising so far.

"We can see the spend is less than what was originally estimated. We can see the timeliness of getting to care is there, and other improvements that have come from this opportunity of being able to have a complete picture of the data coming through the health plan. We will hopefully create a model of care coordination around children in foster care that can be replicated across the country," he says.

Collaboration is Critical to Financial Success
Turning data into actionable information that advances Children's population health goals takes cooperation from both the payer and provider sides of the organization—something that is possible to achieve because everyone involved knows they are in it together as the healthcare industry moves toward value, Duncan says.

"[Children's Community Health Plan] is seen as a trusted partner within our own system. Our primary care physicians, specialty groups, and others understand that by working with us, it gives an opportunity to test different models of care and payment plans and to keep things within the system," he says.

And by working together to lower the cost of care and improve quality and outcomes, Children's can use its population health efforts to strengthen its financial standing, Duncan adds.

"[The health plan is] able to share utilization patterns with primary care groups in our system and get them risk-adjusted and timely data. They can then focus on areas like ED trends, well child visits, and office visit rates. It helps us to get our members appropriate care at the right time at the right price. It's a great opportunity in this day and age with managing populations," he says.

"The nice thing about it is that by having the payer and provider sides working together, the improvements we make are not lost to other insurers. From a consolidated financial standpoint, it stays within the system."