As is widely reported in the news, the healthcare industry is in the middle of a massive transformation. Due in large part to the Affordable Care Act (ACA), the industry is shifting from traditional fee-based care (where providers are compensated due to the volume of patient visits and tests) to value-based care (where providers are rewarded for improving the health of their population).

Ideally, this evolution should benefit everyone within the healthcare industry: patient, provider, and payer.

Unfortunately (although, perhaps, not unexpectedly), this transition has had its share of turbulence.

One example: a recent study by Quest Diagnostics found that only 29 percent of physicians believe they have the necessary tools to function in the world of value-based care. This study also found that as many as 65 percent of those physicians felt that they did not have access to the medical information necessary to effectively treat their patients in a value-based care environment.

The study highlights the disconnect that exists between the drive to provide value-based care and a healthcare organization’s ability to collect, organize, and disseminate the patient data necessary to provide this care.

According to Sanket Shah, a professor of health informatics at the University of Illinois at Chicago, there are three major roadblocks that can affect an organization’s ability to adopt and manage an analytics program:

  • Lack of buy-in from healthcare leadership
  • Cost
  • Poorly trained / unskilled employees

Interestingly, a recent case study indicates that Professor Shah’s theory also works in reverse. When organizations have supportive leadership, a return on investment, and agile, skilled employees, an analytics program can have an immediate impact.

The case study examines GlobalHealth, a regional payer in Oklahoma, and how it created a highly successful outreach program backed by robust analytics that has made a positive impact health on its member’s health and the organization’s bottom line.

Leadership Buy-In

The decision to search for an analytics partner began in 2013, when staff members and executives of GlobalHealth were discussing a member who suffered a recent diabetic coma.

“We were talking about the case,” said David Thompson, chief operating officer of GlobalHealth, “and we started wondering what we could have done to prevent it. Everyone started working backward to piece together the patterns in this case. We realized that if we had all of this data in one central, manageable place, we likely could have made a difference in this member’s outcome.”

“After a lengthy search, we partnered with a company called VitreosHealth,” said Scott Vaughn, CEO of GlobalHealth. “Most health plans look at the members who have generated the most costs historically and focus on them. Whereas VitreosHealth, they look at those members as well, but they also identify members who haven’t generated high costs in the last 12 months but are very likely to have serious health complications in the near future.”

Today, GlobalHealth can successfully predict nearly
70 percent of its hospital admissions. The successes of the program don’t stop there.

“We have experienced an 18 percent reduction in emergency room encounters and emergent hospital admissions for the target population,” said Thompson. “For that same population we have also seen a 22 percent reduction in re-admissions. Our per-member, per-month (PMPM) reduction in medical costs is about 6 to 8 percent, that’s spread across all members. Then if you just look at the members we target and engage, that reduction is even higher.

Download the case study for an in-depth look at how GlobalHealth and VitreosHealth are improving lives and saving money.

Return on Investment

GlobalHealth has created an effective outreach program backed by predictive and prescriptive analytics. In less than two years, this program succeeded in drastically improving overall member health while lowering healthcare costs.

“If you go after the right health outcomes by leveraging predictive and prescriptive analytics to identify and close gaps in care, member health and satisfaction will improve and healthcare costs will be driven down,” said Jay Reddy, president and CEO of VitreosHealth.

Most analytics solutions overlook these hidden risk populations because they do not know how to find them.

“We have had a 10 times return on our investment in terms of what we have paid VitreosHealth and the value we’ve received in terms of reduced healthcare costs,” said Vaughn. “This year, we have an initiative in place that will save us about $25 million. That’s savings we can pass on to members, use to improve healthcare benefits, or reinvest to help us deliver better service.”

Highly Skilled Employees

After launching the analytics program, GlobalHealth realized that the company needed to be adaptable to fit this new approach.

“When we started, we first used our existing case management staff and

weren’t getting the kind of traction that we needed,” said Vaughn. “Our solution was to create a separate unit dedicated to member outreach, and once we did that we started seeing a significantly higher level of success.”

Another shift was to create a new corporate position responsible for funneling information between GlobalHealth and VitreosHealth. In mid-2015, GlobalHealth hired its first director of process improvement and business optimization, Kyle Hager.

Hager interfaces with the predictive analytics partner to refine the data and pinpoint smaller high-risk populations, ensuring that GlobalHealth’s outreach programs are directed where they are most needed. He also frequently communicates with outreach managers and clinicians, listening to their needs and sharing information in order for the predictive analytics partner to refine their service offering.

“What we’re really trying to do is improve quality of life,” said Hager. “That’s why having the right nurses on the phone makes all the difference. We get Meals On Wheels to people, we help them find community services, and we get them a ride to the doctor if that’s what they need. Those are the kinds of things that make or break the program.”

Download the case study for an in-depth look at how GlobalHealth and VitreosHealth are improving lives and saving money.


Healthcare Analytics: Powerful Results Are Possible, Organizational Buy-In Is Required

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