Intro of Data Analysis in Healthcare for Triple Aim

Have you ever heard of Triple Aim in healthcare? If not, you may notice that private and public entities around the world are investigating how to maximize the power of analytics to improve quality of care, operational efficiencies, billing reimbursements with a lower cost. United States spent about 17.9% of GDP on healthcare in 2011, according to World Health Organization’s report.

With such a great opportunity, millions and millions of healthcare data are waiting for analysts to be turned into useful insights and predictions for Triple Aim. This presentation paints a big picture of what you can do with these huge volume and complicated data. What can be turned into reports, predictions, and actions? Analysis of enrollment and emergency department (ED) visits demonstrate the aspects you can dig into.

Moreover, what is the structure for claims? How to use quality measures? You may get a peek from an example of ED visits about how to dig out ED visits from claims.

Lastly, it explains common medical billing and coding, including ICD, CPT, and HCPCS to help you get a good grasp of these coding standards.

Do you know NCQA, NQF, or PQRS?

Do you know how quality measures are set to evaluate physicians’ performance? Below is the list of abbreviation for nationally recognized entities who provide guidelines and requirements for provider transparency methodologies and programs.

ADA: American Diabetes Association

AQA: Ambulatory Care Quality Alliance

AACAP: American Academy of Child and Adolescent Psychiatry

AACE: American Association of Clinical Endocrinologists

APA: American Psychological Association

AHRQ: Agency for Healthcare Research and Quality   

BTE: Bridges to Excellence   

CHIPRA:  Children's Health Insurance Program Reauthorization Act

PQRS: CMS Physician Quality Reporting System

NCQA HEDIS: Health plan Employer Data and Information Set

NCQA DRP: Diabetes Recognition Program

NCQA HSRP:  Heart/Stroke Recognition Program

NQF: National Quality Forum

PCPI: Physician Consortium for Performance Improvement

PQA: Pharmacy Quality Alliance

Quality Measures in Healthcare

What is high quality health care? The answer can be “doing the right thing, at the right time, in the right way – and having the best possible results”. It is often measured in terms of cost, quality, and access as the so-called Iron Triangle of Health Care. Many healthcare programs have been set up to reward the quality of healthcare services, and to help consumers and payers make decision for the best use of their healthcare dollars. Today I would like to give a brief introduction about two common quality measures in healthcare that I learned through my work. One is HEDIS (Healthcare Effectiveness Data and Information Set) measures and the other is Physician Quality Reporting System (PQRS) . These are two main measures used for quality reporting.

HEDIS measures

HEDIS measures are developed, managed, and updated annually by the National Committee for Quality Assurance (NCQA). (NCQA is often referred as the “gold standard” in health plan accreditations. NCQA accredited health plans covers about 70.5% of all Americans enrolled in private health insurance according to NCQA’s own report.)

HEDIS measures address two types of care: preventive health care (children and adolescents, women and adolescent girls, adults, and seniors) and condition-specific care. Condition-specific care can be both chronic conditions and acute conditions. Sometimes HEDIS measures are categorized as chart review measures and claim-derived measures.

Patient-Centered Medical Home (PCMH)

NCQA provides PCMH program with the mission of improving the quality of healthcare. It includes clinical programs such as:

– Diabetes Recognition Program (DRP)

– Heart/Stroke Recognition Program (HSRP)

– Back Pain Recognition Program (BPRP)

Therefore, PCMH quality measures utilize the HEDIS measure set.

Examples of HEDIS measures

Johns Hopkins Medicine’s HEDIS tip sheet of September 2013 demonstrates how HEDIS measures are used by providers. You can see that CPT, ICD-9 codes, and UB Revenue Codes are used for billing purposes.

PQRS measures

On the other hand, Medicare has developed PQRS for its specially covered populations: primarily elder people over the age of 65 or younger with chronic disabilities. You can learn more detailed about PQRS from CMS here.

What do NDC, NCPDP, NABP, NPI mean?

Today I will briefly talk about key terms in healthcare industry that I learned over time.

NDC: National Drug Code

The National Drug Code  (NDC) is a unique product identifier used in the United States for human drugs to identify the vendor (manufacturer), product and package size of all drugs and biologics recognized by the Food and Drug Administration (FDA). It is 10-digit numeric code with 3-segment numeric identifier assigned to each medication listed under Section 510 of FDCA. There are three kinds of combinations for NDC:  4-4-2, 5-3-2, or 5-4-1. 

• The first segment, known as the labeler code, is assigned by FDA. A labeler is any firm that manufactures, repacks, or distributes a drug product.
• The second segment, known as the product code, identifies a specific drug, strength, and dosage form of that drug.
• The third segment, known as the package code, identifies the package size. 

The NDC can be found on the drug container (i.e., vial, bottle, or tube).
 
Pseudo-NDC
NDC derived by CMS (Centers for Medicare and Medicaid Services) is a 11-digit numeric code with a fixed length segmentation: 5-4-2. Since it is different from NDC by FDA, it is sometimes called pseudo-NDC. The NDC examples for diabetic supply list are shown below:

Since July 2013, all outpatient drug claims billed are required to include the J code and a valid NDC (National Drug Code), NDC quantity and NDC Unit of Measure (UOM). The NDC quantity is in the format of 9999.99 while the NDC UOM codes can be

• F2: International Unit
• GR: Gram
• ME: Milligram
• ML: Millilitre
• UN: Unit

The NDCs on claims usually don't contain hyphens or spaces between segments.

NCPDP and NABP

A NCPDP Provider Identification number (NCPDP Provider ID) formerly known as the Pharmacy NABP number, is 7-digit code a to provide pharmacies with a unique, national identifier that would assist pharmacies in their interactions with pharmacy payers and claims processors.

NPI

A National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS) NPPES.

Reference: 

1. CMS NDC 
2. FDA NDC
3. Anatomy Of The National Drug Code