Use Case 19

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Use case summary

• Title: De-identified claims data to analyze referral patterns and out-of-network patient leakage impact
• Work item: https://github.com/demand-driven-open-data/ddod-intake/issues/19
• Activity log: [DDOD activity log for use case](https://docs.google.com/spreadsheets/d/1acv8kB-HTtMxvuM7HPtMrNx6vIqjpWvjeAUCRoVS_-4/gviz/tq?gid=0&pli=1&tqx=out:html&tq=SELECT B, D, E, F where A=19)
• Solution: https://github.com/demand-driven-open-data/ddod-intake/wiki/Solution-19

Description

• Need to obtain claims datasets at the provider-level in order to perform analysis of provider referral patterns and patient leakage out of given ACO networks to determine leakage’s downstream impacts on financial performance and care quality.

Value

• Value to customer: _____
• Value to industry/public:
  • Repatriate referrals to a given ACO network to better control costs, improve financial performance, and improve care coordination
  • Promote referrals to physicians with superior clinical outcomes
  • Develop comprehensive view of referral patterns to better understand and promote patient access to care
  • Reduce inappropriate or duplicative care; promote preventative services and lower-cost care

Customer

• Referral management and population health SaaS company

Current data and limitation

• Data source: _____
• Challenge: Provider-level claims are not currently available for such analysis

Specifications

There are 3 datasets needed:

• De-identified patient data, yet still in a format to allow for longitudinal patient tacking
• Adjudicated claims to understand the financial impact of leakage
• Roster of MSSP ACO and Pioneers ACO providers by NPI Number

De-identified patient data

• Purpose: Longitudinal patient tacking
• Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
• Fields: _______
  • Patient ID: Need an arbitrary pseudoidentifier to allow for longitudinal patient tacking
  • __(needs to be filled out)
• Update frequency: _______
• Joins between datasets: _______

Adjudicated claims

• Purpose: To understand the financial impact of leakage
• Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
• Fields: _______
  • Provider NPI Number
  • __(needs to be filled out)
• Update frequency: _______
• Joins between datasets: _______

MSSP ACO and Pioneers ACO providers

• Purpose:
• Description: Roster of MSSP ACO and Pioneers ACO providers by NPI Number
• Fields: _______
  • Provider NPI Number
  • __(needs to be filled out)
• Update frequency: _______
• Joins between datasets: _______