Why are patients such a mystery? Steve Whitehurst has ideas

Health Fidelity is trying to help carriers, and providers, do a better job of finding and organizing the health record information they need to analyze how sick patients really are.

The company has developed a process for getting records out of proprietary record systems, emails, individual physicians’ computers, and even their paper files. The company then puts the records through computer systems that can make sense out of natural language.

Once insurers locate, structure and analyze all of that patient health information, “they’re surprised by how much additional risk they find,” Steve Whitehurst, Health Fidelity’s chief executive officer, said last week in an interview. 

See also: PPACA risk system may get 9 billion claim records per year

Identifying health risk buried in scattered health records may be a great way to come up with ideas for improving patients’ health, such as identifying the patients who ought to be invited back for thyroid test follow-up tests.

Program architects at the U.S. Department of Health and Human Services (HHS) have raised the stakes even further by tying provider and carrier compensation to patient risk analysis programs. HHS program designers see use of health record-driven risk-adjustment programs as a way to compensate providers and carriers for the cost of working with high-risk patients, and to give providers and carriers a financial incentive to focus on improving the high-risk patients’ health.

In the Medicare Advantage market, the Medicare Advantage risk-adjustment program helps determine how much the Medicare program pays a carrier.

In the PPACA risk-adjustment program, carriers with what appear to be relatively low-risk enrollees are supposed to send cash to the carriers with what appears to be higher risk enrollees.

See also: Actuary: PPACA drags insurers into diagnosis code war

When carriers develop risk analyses for the PPACA risk-adjustment program, “they’re looking for protection,” Whitehurst said.

Managers of some of the failed Consumer Operated and Oriented Plans (CO-OP) have complained that unfair PPACA risk-adjustment program rules contributed to their demise. One of their arguments is that older, better-established carriers were in a better position to identify high-risk enrollees.