Clinical Data: The New Best Friend of Medicaid Managed Care Organizations


Electronic health records and the data created are being used on multiple levels and continue to be a driving force for improving care and lowering health care costs.

Since the start of the 20th century, data have played a huge role in health care. Gone are the days where the archaic practice of charting a patient’s medical history with pen and paper was commonplace. Today, electronic health records (EHRs) and the data created are being used on multiple levels and continue to be a driving force for improving care and lowering health care costs.

No one knows this better than managed care organizations (MCOs). Especially, those MCOs that are contracted with Medicaid to deliver the benefits and services included within a member’s Medicaid plan.

According to the Kaiser Family Foundation, 39 states contracted with MCOs in 2017 and 75% of all Medicaid beneficiaries, in 28 states, were enrolled in MCOs in 2016. MCOs help states (Medicaid is a state funded program) control health care expenditures by improving plan performance, increasing the quality of care, and increasing desirable outcomes.

For many years, MCOs have relied primarily on claims data to find new and different ways to improve care and control costs and spending. But in recent years, MCOs are finding that using mainly the billing interactions (claims data) between the insured members and the health care delivery system is a leaving out part of the equation.

Medicaid MCOs are trying to get a better handle on their ability to implement data and utilize strategies to improve care and improve costs. Their answer: clinical data implementation.

If MCOs can integrate clinical data into their overall strategy, they can use it to develop a better understanding of their patient’s health care trends and habits. Clinical data can give MCOs a comprehensive snapshot of the member that will enable the payer to facilitate better case management and quality reporting, while simultaneously empowering MCO provider networks to effectively manage their patient populations.

So, the question becomes: what strategies do MCOs need to develop to integrate clinical data into their cost saving and improvement of care initiatives?

Firstly, MCOs need to identify what sort of data infrastructure that they want to use to transmit and share their data. Typically, data support that the majority of patients whose health care services are sponsored through Medicaid are more likely to be burdened with a chronic condition and/or comorbidity.

This patient demographic needs to have their clinical information shared and disseminated across multiple provider networks and health care systems in various digital formats because of the level of complexity of medical conditions for this particular patient population.

If a more standardized system to store and communicate these data is established, and the transmission of the data is more effectively integrated across provider networks, the care for this unique patient population can be optimized. Next, MCOs also need to consider the source of their data, as well as the format in which those data are transferred when considering data standardization.

Why? Simply put, the playing field is complicated and lack any type of gold standard.

Today’s data sources include:

  • EHRs
  • state immunization and disease registries
  • health information exchanges

Today’s data formats include:

  • admission transfer and discharge
  • continuity of care documents
  • patient files

However, it is important to note that when I state that MCOs should use more clinical data to aid in their delivery of care, I am talking exclusively about claims data. There is a difference and it is important to distinguish them. Claims data offers information on the services (the who, what, where, when and why) that were provided to a patient during their journey through the health care system. This time period is often over a measured over many years.

Clinical data provides a greater degree of knowledge and insight on each patient. With clinical data, we can get a comprehensive snapshot on the services that were provided and the resulting outcomes of those services.

So what’s the difference then? Well, it’s the data that are collected.

Although claims data will list medical tests administered to a patient, it’s the clinical data that provides the results of those tests. You can think about it this way: claims data are the recipe, but clinical data are the cake. Clinical data can provide Medicaid MCOs with informative and useful risk and case management information.

Risk management is a common tool that is used by plan sponsors to predict a member’s service utilization and the costs associated with that patient’s delivery of care. MCOs can use risk management to better target the unique needs of different populations, rather than taking a cookie cutter approach and treating all patient populations similarly.

This unique and specific targeting can be achieved by means of risk adjustment, a process that separates each member into demographic, morbidity, and/or disease categories. If MCOs can use their clinical data to better understand their patient populations and the risks associated with the demographics within those populations, delivery of care, and the cost associated with that care can be optimized.

But what about case management? When MCOs talk about case management, they are referring to the services that the organization can provide to patients to assist them with access to various services, including medical, social, and educational resources.

Clinical data fit into case management in that MCOs can use the data to empower their case managers to engage and guide their patients to the appropriate services with specific care plans, referrals, and monitoring activities.

But before we get too far ahead of ourselves with all the ways Medicaid MCOs can benefit from clinical data, it is important to identify some of the challenges. Data variability is a significant issue. The sheer volume of data alone can be rather bewildering to try to interpret, let alone standardize. Even if MCOs have an abundant source of data within their EHR system, MCOs often find it to be an arduous task to try and isolate pertinent data points from EHR documents.

Another barrier is a changing organizational culture. As more MCOs try to understand the important differences between claims data and clinical data, often the value of those data can be overlooked or misunderstood. When a Medicaid MCO transitions from the use of primarily claims data to the use of clinical data to improve care, additional training of staff is often required to build the knowledge and skillsets required to interpret and use those data.

Providers also can be a barrier to an MCOs use of clinical data. Some providers are hesitant to share their data with the MCOs and often require some sort of an established incentive before they are willing to exchange information. But regardless of these barriers, one thing seems to be obvious: MCOs need for clinical data is significant.

As business processes continue to mature, Medicaid MCOs should continue to rely on the use of clinical data as the basis for analyzing care, optimizing clinical workflow, and improving the delivery care.

About the Author

Ryan Stept, MSc earned his Masters of Science in Healthcare Administration from Saint Joseph's University and is currently enrolled in the Masters of Pharmacy Business Administration program at the University of Pittsburgh. The program is a 12 month executive-style, graduate education program where healthcare professionals obtain an in-depth understanding of the business of medicines. Currently, Ryan works for the University of Pittsburgh, School of Pharmacy, Program Evaluation and Research Unit as a research specialist. Ryan’s research is primarily focused on the opioid epidemic and provides technical assistance to stakeholders across the commonwealth in their mutual efforts to reduce opioid death rates in Pennsylvania.

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