Improve cost and quality outcomes through early comorbidity detection | Geneia

Improve Cost and Quality Outcomes Through Early Comorbidity Detection

June 22, 2017
Kevin Rill, Head of Solutions Architecture

A top focus of value-based care is developing the ability to consistently get upstream of adverse health events – to identify, organize and treat members by their level of risk before they need expensive and invasive services. Nowhere is this more important than in the identification and care of members with multiple chronic conditions or comorbidities. 

To break it down:

  • About 50 percent - 117 million - of adult Americans have at least one chronic condition.
  • More than one in four Americans have two or more concurrent chronic conditions.
  • Put another way, more than half of the people with one chronic condition have at least one more – that’s 60 million Americans with multiple chronic conditions (comorbidities).

As a nation, we are getting older. Americans turn 65 at the unprecedented rate of 10,000 per day (a rate that began in 2011 and is projected to continue until 2030). 

  • In Americans aged 65 or older, the incidence of multiple chronic conditions increases to three in four
  • The financial burden is high. People with multiple chronic conditions cost up to seven times more than those with a single chronic condition. 
  • 86 percent of all healthcare spending is for people with one or more chronic conditions.
  • 38.5 percent of all inpatient stays are for people with five or more chronic conditions.
  • 71 percent of all healthcare spending is for people with two or more chronic conditions (that’s 71¢ of each healthcare dollar going to people with multiple chronic conditions).

The impact of members with comorbidities is felt across the board – from worsening health outcomes at the patient-level to exponentially increased risk, utilization and cost at the system-level. For health plans, seeing the big picture is the first step. The next step is accurately predicting what is most likely to happen next so physicians and care teams can get upstream.

Challenges of Early Detection

Undiagnosed and unsuspected comorbidities can quickly and exponentially worsen a situation because treatment for the first condition often conflicts with the second. If the subsequent condition can be detected early, appropriate adjustments can be made to the member’s treatment plan.

Controlling the onset of a second (or third or fourth) chronic condition is a complex task. That’s where analytics can help.

Isolation of Data

The first challenge is overcoming the isolation of information. Clinical notes alone only provide a partial picture of any one person, especially when electronic health records are not easily shared between the primary care physician, hospitals and specialists. The same is true of claims data – it provides a wealth of information, but still not the whole picture. 

It is only when clinical and claims data are combined (and further enhanced with lab, pharmacy and other data) that a full picture of any person becomes possible. With this type of comprehensive picture, physicians are better able to understand their patients.

Unfortunately, many health plans and health systems are still using data systems that were simply never designed for – and aren’t capable of – fast and accurate data aggregation from multiple sources.

Sophistication of Analytics

Healthcare analytics is a big and crowded industry. One differentiator setting market leaders above the rest, according to Chilmark Research is, “the ability to address comorbidities.”

The Theon® platform ties together and constantly scours disparate data for disease markers to assist physicians in the accurate and early diagnosis of comorbidities. We proactively identify members at risk, or suspected of being at risk, for developing additional chronic conditions or progression of existing conditions.

For example, Geneia’s algorithms compare patients with one diagnosed chronic condition against everyone else with a different chronic condition. We search for similarities across age, demographics, consumer data, lab results, and pharmacy data. As similarities are discovered, data is further analyzed for indicators pointing to the likelihood of an undiagnosed chronic condition.

Quality Measures and Coordinated Care

People with multiple chronic conditions require complex case management. Each condition requires a certain set of services within an established timeframe to help control and monitor disease progression. Any single condition carries a multitude of measures, services and checkpoints. As conditions are added, the complexity and chance that needed services will be missed increases. 

Keeping track of these services and reconciling the requirements for multiple conditions is critically important to value-based care as reimbursements, quality ratings, risk factors and cost utilization are all tied to quality measure reporting.

Again, analytics can help.

Sophisticated analytics helps providers navigate the complicated needs and reporting requirements of comorbid members. The Theon® platform ties together multiple care plans with multiple required quality measures and simplifies next steps. By summarizing information from various clinical sources like specialists and adding in claims data, the platform helps physicians to look beyond the here and now within their exam room. By reconciling this aggregated data against multiple quality requirements, analytics helps simplify complex scheduling and reporting of quality measures.

When data is constantly aggregated and analyzed, and insights transparently shared across providers (doctors, specialists, case managers, social workers, etc.) and care settings, then the entire care team is better able to understand the patient from a holistic standpoint to deliver cost-controlled care without redundancies and conflicting and confusing treatment plans. 

Few analytical solutions provide true comorbidity detection. Fewer still are capable of helping care teams turn insights into cost-controlled, coordinated care that improves patient outcomes. Geneia’s Theon® platform helps health plans and their provider networks detect suspect comorbidities early and, once detected, helps slow the progression of disease through simplifying complex care requirements.

We help our clients get upstream of multiple chronic conditions and deliver cost-controlled, high-quality care that improves outcomes for their most vulnerable and complicated members.

Graph - U.S. Healthcare Spending and Chronic Conditions Percentages

Graph - U.S. Healthcare Spending and Chronic Conditions

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