Gary Stanford, Vice President & Actuary, Network Analytics
Health Care Service Corporation
Health Care Service Corporation was faced with the challenge that traditional evaluations of fee-for-service costs do not adequately capture the performance of providers. More robust cost measures are needed, balanced with measures of quality and accurate coding. This is complicated by the fact that patient care is often provided by an array of primary care physicians, specialists, hospitals and ancillary providers. As such, a holistic view of costs across episodes of care is required. Equally important are the connections and interactions among providers and the impact those have on member care and network performance.
A phased approach was taken with separate projects for each dimension of cost efficiency, clinical quality and coding accuracy. The first phase focused on efficiency by bundling claims into episodes of care, then comparing the cost of attributed episodes for each provider to similar episodes treated by peers. Providers’ connections to other providers, as evidenced by shared patients, were also analyzed to gain insight into the overall impact of network composition. Predictive modeling is used as a means to understand potential drivers of performance, such as group and hospital affiliations. A full suite of reporting is being developed to provide transparency and help providers understand their results with actionable insights to improve. Lastly, results are incorporated into tools that simulate the performance of alternate networks and the impact of modifications to existing networks. The coding accuracy phase of this project has been completed, and the clinical quality phase of this project is underway, led by HCSC clinical leaders in collaboration with a broader community of industry clinicians working to identify appropriate metrics and data sources.
This solution greatly enhances HCSC’s ability to improve member care and reduce costs by developing high performing networks, modifying care patterns, engaging and educating providers to enhance performance, improving transparency and identifying opportunities to implement alternative payment models.