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Putting claims data to work: Using analytics in an evolving healthcare ecosystem

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As the US healthcare ecosystem undergoes rapid evolution, hospitals and health systems need up-to-date analytics to manoeuvre and thrive. National claims data that is both robust and reliable can provide the basis for such analytics. Data reflecting billed charges and negotiated (or allowed) amounts can inform fee schedule development, payer negotiations and dispute resolution. Claims data, which includes procedure and diagnostic codes and relevant demographic factors, also reveals important trends and patterns in four alternative venues of care: retail clinics, telehealth, urgent care centres and ambulatory surgery centres. Factors considered include rural versus urban growth in utilisation, patient age groups, gender utilisation and common diagnoses. The paper also presents clinical trends illuminated by claims data analysis for the following conditions or procedures: obesity and type 2 diabetes in paediatric patients, psoriatic arthritis, Lyme disease, breast cancer, knee and hip surgeries and opioid abuse and dependence. Issues in the analyses include comorbidities, costs and gender and age disparities. Finally, the paper suggest how claims data can be a basis for bundled payments and associated analytics to aid in the transition from a fee-for-service model to value-based reimbursement or otherwise shed light on provider performance.
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Keywords: bundled payment; claims data analysis; clinical trend; place of service; value-based reimbursement; venue of care

Document Type: Research Article

Publication date: January 1, 2018

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  • Management in Healthcare is the major new professional journal publishing in-depth, peer-reviewed articles and case studies on leadership, administration and management in healthcare. Content will be written by and for healthcare management professionals and researchers with no advertising or sales pitches.

    Each quarterly 100-page issue – published in print and online – will feature detailed, practical articles on key business issues which cut through the deluge of information facing healthcare management professionals to showcase the latest thought leadership in how to deliver more with less resources while at the same time improving healthcare quality, along with actionable advice and ‘lessons learned’ from fellow healthcare managers to put that strategy into practice. It will not publish advertising but rather detailed analysis of new thinking and practice at a wide range of healthcare providers worldwide for readers to benchmark their organization against, with every article being peer-reviewed by an expert Editorial Board to ensure that it focuses on the healthcare manager’s perspective, the challenges they face and how they can tackle them.

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