Episodes of Care Management using Payer Claims Data

Dogu Celebi, MD, Chief Medical Officer; Dan Dunn Ph.D., Chief Technology Officer, and Nick Hilger, Senior VP, Ingenix Health Solutions. Increasingly CMS and Commercial Insurers are using claims data to evaluate the care of a patient across different delivery venues. Hospitals, physicians, laboratories, imaging centers, pharmacies, and post-acute care centers have encounter (claims) data for their specific venue, but they don’t typically share that information among themselves. Payers, however, have all the claim (encounter) data for individual patients across the continuum. Ingenix has provided analytic tools to payers and government agencies to allow them to group the care elements, benchmark them against specialty society endorsed evidence-based medicine guidelines, and create report summaries that measure performance of the care delivery network. Health Systems could also better understand the total episode of care elements to manage the care of individuals. These tools can now be used by health systems to allow them to see the total episode of care utilization of their networks and have more transparent conversations with payers in Pay for Performance dialogues.