Data Revolution: The Need for Accurate Data to Drive Quality Analytics

The Affordable Care Act (ACA) made a tremendous impact on the healthcare industry. What was once a free-flowing commercial market with very low requirements and data interaction has now transformed—it has morphed into a highly-regulated market heavily dependent on data to deliver quality outcomes for members and to remain financially sound. The processes set forth in the ACA mirror existing Medicare processes with adjustments in order to make the processes work for the Commercial population.

With the introduction of the ACA, data has had a staggering increase of importance and has become an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans’ minds. Daily, health plans rely on the accuracy of their data for analytics which drive business decisions related to such things as rate setting, risk score calculations, federal and state data submission, and population health management. All too many health plans “assume” the information they are receiving from their membership, claims, and provider platforms into their data warehouse is accurate. This assumption is based on the fact these systems are considered to be “the source of truth.”  This terminology leads to false reassurance that just because it’s the truth, it also means it’s accurate. Always trust, but verify the data utilized. Inoperability between systems and software is a huge issue which increases your risk of losing data during transmission of information. Refined data management process and data governance are the links needed to bridge the data gaps.

When speaking about data and data management, the immediate correlation is to think of it as an IT department responsibility. With the growing regulations and oversight from the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) around data, it has now also become a business responsibility. Long gone are the days when a business area could simply submit a change request and not be a part of the IT functions to implement the change. It is a critical piece now to have the business department working side by side with the IT department to ensure the changes or updates being implemented are accurate and within the regulations set forth by the regulators. As we all know, CMS and HHS can have last-minute changes and hard deadlines to which health plans must adhere. Knowing that working to meet these deadlines can be strenuous to achieve and realizing the IT infrastructure within your organization is increasingly complex, the business needs to be working with IT daily to notify them of any changes related to their work. Such items would include changes to the deadline, format, or field requirements, to name a few. It is a much more agile process than ever before. Having a business area who understands the technical components and effort needed to complete a desired change along with the required regulations leads to a much more successful engagement between IT and business.

There was a release on October 6, 2015, from HHS regarding rules to advance electronic health records with added simplicity and flexibility. HHS recognizes there is a need to make health information available quickly and easily to those who need it, as noted by the comment from Karen B. DeSalvo, M.D., M.P.H., M.Sc., national coordinator for health IT.  She stated, “This rule is a key step forward in our work with the private sector to realize the shared goal of making actionable electronic health information available when and where it matters most to transform care and improve health for the individual, community and larger population.   It will bring us closer to a world in which health care providers and consumers can readily, safely and securely exchange electronic health information.” This is a huge advancement for HHS. Health plans need to establish and perfect their data infrastructure now so, as advancements occur within other areas of the industry, they are able to receive and store information utilized for analytics.

Here are some important questions to ask yourself when it comes to your organization:

1. Does your organization have a solid data management process in place to account for CMS and HHS requirements which could withstand an audit?
2. Has a clear understanding been established on the inoperabilities existing within the company and established ways to remedy any issues which may occur? 
3. Has data governance been established?
4. Are integrated analytics established throughout the areas highly focused on member and provider engagement to support risk adjustment and Star Ratings?
5. Is your organization able to analyze population health management information easily and effectively on a consistent basis?

If you answered “no” to any of these questions, you will want to evaluate your current structure to identify areas of opportunity. The data within your organization provides the knowledge you need to understand your organization, members you serve, and maintain your financial solvency. Clean data to drive quality analytics is something every health plan wants. You need to ensure you have the right processes in place to manage the data within your organization effectively to set yourself apart from your competitors.

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