Use Case 19: Out-of-network patient leakage impact

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Requirements

Use case summary

  • Title: De-identified claims data to analyze referral patterns and out-of-network patient leakage impact
  • Work item: demand-driven-open-data/ddod-intake#19
  • Status: Inactive due to lack of specifications from requester.

Description

  • Need to obtain claims datasets at the provider-level in order to perform analysis of provider referral patterns and patient leakage out of given ACO networks to determine leakage’s downstream impacts on financial performance and care quality.


Value

  • Value to customer: Richard Ferrans, MD
  • Value to industry/public:
    • Repatriate referrals to a given ACO network to better control costs, improve financial performance, and improve care coordination
    • Promote referrals to physicians with superior clinical outcomes
    • Develop comprehensive view of referral patterns to better understand and promote patient access to care
    • Reduce inappropriate or duplicative care; promote preventative services and lower-cost care

Customer

  • Referral management and population health SaaS company
  • Richard Ferrans, MD
  • Fred Trotter

Current data and limitation

  • Data source: Detailed claims data is available internally at CMS (for Medicare/Medicaid) and payers.
  • Challenge: A complete dataset of provider-level claims are not easily available outside of payers for claims leakage analysis


Specifications

There are 3 datasets needed:

  • De-identified patient data, yet still in a format to allow for longitudinal patient tacking
  • Adjudicated claims to understand the financial impact of leakage
  • Roster of MSSP ACO and Pioneers ACO providers by NPI Number


De-identified patient data

  • Purpose: Longitudinal patient tacking
  • Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
  • Fields: _______
    • Patient ID: Need an arbitrary pseudoidentifier to allow for longitudinal patient tacking
    • ______(needs to be filled out)____
  • Update frequency: _______
  • Joins between datasets: _______

Adjudicated claims

  • Purpose: To understand the financial impact of leakage
  • Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
  • Fields: _______
    • Provider NPI Number
    • ______(needs to be filled out)____
  • Update frequency: _______
  • Joins between datasets: _______

MSSP ACO and Pioneers ACO providers

  • Purpose:
  • Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
  • Fields: _______
    • Provider NPI Number
    • ______(needs to be filled out)____
  • Update frequency: _______
  • Joins between datasets: _______

Solution

Workaround

"...ACO members are required to release their providers on their websites.", per Fred Trotter

  • However the NPI field is missing from such data.
  • Ultimately, there would be a benefit from CMS releasing NPIs belonging to each ACO with each Monthly CCLF (Claims and Claims Line Feed) file release. (Source: @FTrotter)

Solution #1: CMS's referral data

Warning: Potential data problem as of 10/5/2015

DocGraph had a recent data retraction associated with the Teaming dataset mentioned here.
Details and possible fix is posted at http://www.docgraph.org/notice-teaming-data/.

CMS now has physician referral data available at https://questions.cms.gov/faq.php?faqId=7977 that in essence shows referrals from one physician to another.

  • It was provided as a response to FOIA requests and analytics efforts by Fred Trotter at DocGraph.
  • It works on the following definition of referral:
A referral occurs when an organization or provider participating in the delivery of health services to the same patient in up to one-month period, after another organization or provider participated in providing health services to the same patient.


Files for download

  • Physician Referral Patterns - 2009  zip
  • Physician Referral Patterns - 2010  zip
  • Physician Referral Patterns - 2011  zip
  • Physician Referral Patterns - 2012 - 2013 30 day interval  zip
  • Physician Referral Patterns - 2012 - 2013 60 day interval  zip
  • Physician Referral Patterns - 2012 - 2013 90 day interval  zip
  • Physician Referral Patterns - 2012 - 2013 180 day interval  zip
  • Physician Referral Patterns - 2012 - 2013 365 day interval  zip
  • Physician Referral Patterns - 2013 - 2014 30 day interval  zip
  • Physician Referral Patterns - 2013 - 2014 60 day interval  zip
  • Physician Referral Patterns - 2013 - 2014 90 day interval  zip
  • Physician Referral Patterns - 2013 - 2014 180 day interval  zip
  • Physician Referral Patterns - 2013 - 2014 365 day interval  zip

Solution #2: DocGraph

Various versions of referral data is also available from commercial and open source entities. One example is DocGraph / CareSet. For those who don't want to do perform manual manipulation of text files, these data sources provide data that is cleaned up, pre-processed, and made accessible in a way that's easier to work with.