Business intelligence tools are invaluable in monitoring high-priced specialty drugs and reining in costs when medically appropriate.
Like many healthcare organizations, Marshfield Clinic Health System in Marshfield, WI, is focused on achieving the triple aim of lowering the cost of care, improving outcomes and the health of populations, and enhancing the patient experience.
Security Health Plan of Wisconsin—Marshfield's health insurance arm, which provides coverage to more than 200,000 people throughout 32 counties in the state—is using a number of tactics to assist the organization with these efforts, says Mark LePage, MD, Security Health's chief medical officer.
Aligning Incentives
One major key to success, LePage says, is to align financial incentives in a way that will help break down the traditional barriers that exist among healthcare providers and insurance companies.
"There has always been between any payer and provider a bit of an adversarial relationship. One of the glide paths we are on as a system is to look at how we can align ourselves more, and a big part of that is putting in financial constructs that align incentives."
Getting both sides of the organization on the same page when it comes to the kinds of financial inducements that encourage cost savings will position Marshfield well as the industry moves toward value and away from volume-based, fee-for-service medicine, LePage says.
For example, he says, the health plan is rewarding providers for reducing waste and for adhering to more standardized, evidence-based clinical protocols.
"This is, I believe, a win-win-win," he says. "The patient wins because we are focused on delivering optimal care. The providers win because we are doing it in a way that they can be advantaged financially, and the health plan wins financially, as well. That is the art of putting together well-constructed value-based plans. As they become more prevalent, we will over time get incentives aligned more appropriately. That is part of the work we are doing."
Using Business Intelligence Tools
The success of value-based reimbursement structures hinges on providers being able to find sustainable efficiencies that lower the overall cost of care. Security Health's claims data and business intelligence capabilities help Marshfield do just that, LePage says.
"Obviously, claims data goes into a lot of risk stratification in terms of risk scoring, and that is certainly helpful for the care management programs because we can focus on the high-risk populations. The bigger opportunity at the health plan comes from us having built out a robust business intelligence unit," he says.
"In large part, we use that to look across patterns of utilization by different disease states and find where there are pockets of unwarranted variation in the resources being used to care for populations. It can help us find areas where we are doing well and areas where there are opportunities to improve."
For instance, LePage says, the organization uses its BI tools to pay close attention to the use of high-priced specialty drugs and to rein in costs when medically appropriate.
"We use our business intelligence unit to compare ourselves to other organizations across Wisconsin to see how we are doing relative to using resources on a risk-adjusted basis in caring for populations," he says.
"We ask ourselves, 'Do we have pockets in certain disease states where we are using more expensive drugs than perhaps other organizations are in managing similarly risk-adjusted populations?"
By pinpointing opportunities to cut costs and rewarding clinicians for maximizing savings, Marshfield can continue to shift in the direction of value, LePage says.
"When I look at how we can move the healthcare system forward … it is really taking those value-based financial constructs that incent both payers and providers to minimize waste," he says.
"We want to position both payers and providers around the patients' needs and combine that with an active business intelligence unit focused on measuring waste. That is a meaningful construct for moving the system."
Funding Patient-Centered Care Programs
In addition to its BI unit, Security Health has achieved cost savings and improved care by funding programs designed to provide extra support for high-cost, at-risk plan members, LePage says.
"One of the populations we have identified is heart failure patients, who are obviously prone to frequent and unnecessary emergency department visits, hospitalizations, and readmissions. The clinic has had for a long time a heart failure program, and on the health plan side we could see that providers are doing a good job working with these patients," he says.
"It made sense for us to support this service for our members so we worked together to put an agreement into place to fund the program for our members. This generated a reduction in unnecessary ER visits and hospitalizations, and it also generated a cost savings."
Security Health also focuses on patients with behavioral health issues, who tend to be very high utilizers of healthcare resources.
Care coordinators are placed within Marshfield's primary care offices to work closely with patients' psychiatrists and assist the primary care physicians with managing patients' medications and other health needs.
The health plan pays a monthly program fee per plan member who uses these services, LePage says, adding that it has been a successful way to help behavioral health patients receive the care they need despite Wisconsin's dearth of psychiatrists.
"Like in a lot of parts of the country, there is a real scarcity of behavioral health resources in our area. … We have integrated [these] resources at the primary care level to enable better care for patients with depression and anxiety," LePage says.
"It's a good model for expanding access to behavioral health services and the health plan can support this in a financially sustainable way. … It's a way to amplify the impact of both the psychiatrists and primary care physicians to provide better care for patients."