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IBM Rules Engine Offering Presenter Name Presenter Title Date
IBM Rules Engine offering
Our audit solution
• Analytic methodology that can calculate complex industry-standard quality measures that
reflect evidence-based medicine. These types of measures can be adopted as:
Comprehensive
─ Physician performance indicators appropriate for public
“100% reporting
of Claims” (accountability)
Audit
and pay for performance, as well as quality improvement
• Re-adjudicate 100% of your claims to
identify screenings,
─ Checklists for individual patients that reflect appropriate potentially erroneous claims
tests and
treatments specific to their situations • Customized audit rules built from
your SPDs
• Can handle sophisticated logic to look across eligibility and claims •forFrauda given patient,
• Industry •standards
Administrative
and other
condition and the physicians providing services
proprietary audit rules
• Clinical
• Basic fraud & abuse rules
• IBM® Rules Engine offering generated measures enable healthcare analysts to evaluate
the completeness of care delivered • Onsite review of focused sample of
medical claims identified through re-
adjudication process
• Operational review (medical
administrators only)
Analytic use scenarios
• Rules Engine generated measures enable healthcare analysts to
We conducted evaluate, at the patient and provider level, the completeness of
side-by-side care delivered
Data Rule Logic – Enables evaluation of retrospective and prospective returns
stratified random on healthcare investments
sample and 100%- – Enables consumer responsibility through reporting
frameworks summarizing gaps in care
of-claims audits on – Enables physician understanding of absolute and relative
performance and (in future) action lists, reminders
the same carrier
Rulesfor
Engine
– Within ad-hoc reporting, they can be viewed together with
Client A. the vast array of utilization and cost measures to help
determine quality-efficiency relationships and trends
• Incorporating quality measures in decision support framework
– Provides evidence-based guidelines for measuring quality
on your book of business for care management/disease
management purposes
Reporting Results Actions
Analytic use scenarios – types of reporting
Performance Reporting
• Compare and analyze performance of physicians, plans or other entities
Trend Reporting
• Monitor compliance and prevalence rates over time
• Fraud
• Administrative
• Clinical
Care Program Evaluation
• Evaluate ROI on program performance
• Help identify gaps in care for patient care
• Patient identification or stratification for intervention or education
Financial Impact Assessment
• Evaluate the impact of non-compliant care, inappropriate care and under- or
over-utilization
Case study example – antibiotic use for bronchitis
Problem statement
• With more than 100M ambulatory visits in the US, acute bronchitis is one of the most
common clinical conditions seen in outpatients1. This viral and self-limiting respiratory
condition is treated with antibiotics in 60 to 90 percent of patients who seek care2,3,4.
Bronchitis is more likely to be treated unnecessarily with antibiotics than other respiratory
conditions5.
• Inappropriate use of antibiotics could lead to an even bigger problem- antibiotic-resistant
bacteria. Overall antibiotic use in acute bronchitis is ineffective and wasteful6.
• The evidence-based medicine approach to acute bronchitis is reassurance and
symptomatic treatment7. Guidelines by the National Committee for Quality Assurance • Fraud
(NCQA), National Quality Forum quality (NQF), National Institute for Health and Clinical • Administrative
Excellence (NICE) and the Centers for Disease Control and Prevention (CDC) recommend • Clinical
against use of antibiotics8,9,10,11.
Using the results
• Through reporting, patient and provider lists can be generated.
• Providers with low compliance rates can be identified for quantitative feedback and education supported by guidelines.
• Quality based reimbursement initiatives can use results data to identify high performers, to design and scale reimbursements.
• If care is delivered in compliance with evidence-based medicine guidelines, cost of care could decrease.
Note: Footnotes 1-11 are listed on slide 10
Case study example – preventive services
Problem statement
• The United States remains one of the world’s richest and most technologically
advanced nations, however our national health continues to fall far short of
expectations and the associated costs are alarmingly high12.
• For years the case for preventive medical services has been made as one of
the best solutions to improve the healthcare problem at all levels. Though a lot
of progress has been made, preventive medicine services still have many
challenges13,14.
• Despite being widely available, the utilization of preventive services remains
low.
• Fraud
• Preventive Services and Colorectal Cancer: Colorectal cancer is one of the
most frequently diagnosed cancers in adults and the second leading cause of • Administrative
cancer deaths in the US15. It is estimated that up to 500,000 deaths have been • Clinical
prevented in the US by CRC screening16. However, only about 60% of adults
are screened by current guidelines17.
Using the results
• Through reporting, patient and provider lists can be generated.
• Providers and consumers with low compliance rates can be identified for quantitative feedback and education supported by guidelines.
• Improvements to quality of care are possible with early detection, delayed onset or limited progression and can ultimately improve the
mortality rate.
• If care is delivered, in compliance with evidence-based medicine guidelines, total cost of care could decrease.
Note: Footnotes 12-17 are referenced on slide 11.
Measure Packages
• Rules Engine measures are available as an additionally priced
Ouroption
audit solution
• The measures are arranged in measure packages, groupings of measures that can be used for similar analytic
Comprehensive
purposes
“100% of Claims” Audit
• The measure packages are as follows: • Re-adjudicate 100% of your claims to
identify potentially
– Physician Focus (62 measures) – clinical performance measures endorsederroneous claims
by nationally recognized entities
such as the National Quality Forum (NQF) • Customized audit rules built from
– Disease Management Focus (43 measures) – measures around your SPDs • Fraudcommonly targeted for Disease
conditions
Management programs/interventions • Industry •standards
Administrative
and other
proprietary
• audit rules
Clinical
– Health Plan Focus (60 Measures) – quality measures based on HEDIS health plan specifications that address
preventive services, chronic disease management, behavioral healthfraud
• Basic care,&appropriateness/overuse
abuse rules of services
and value • Onsite review of focused sample of
– Medicaid Focus (60 Measures) – quality measures for Medicaid
medicalpopulations basedthrough
claims identified on criteria
re- from the NCQA
adjudication
and the U.S. Department of Health & Human Services’ Agency processResearch and Quality
for Healthcare
– Client specific – we can create customized new measures based on business
• Operational need
review (medical
administrators only)
Measure packages – examples of measures
• Diabetes HbA1c • Acute Bronchitis Tx • Diabetes and CAD • COPD Exacerbation
Management wo Antibiotics Statins Recommended
• H Influenza Type B
• CAD: Beta-Blocker • ADHD Drug • Hypertension Annual Vaccines
Therapy-Prior Management Creatinine
Disease Management Focus
Myocardial Infarction • Depression ED visit • Hepatitis A Vaccines
• Annual Monitoring of after 6 weeks • Hepatitis B Vaccines
Physician Focus
• Childhood Persistent Medications
Immunization Status • Heart Failure CBC
Health Plan Focus
• Asthma Medication Recommended Early • Influenza Childhood
• Breast Cancer Management Vaccines
• Asthma ED utilization
Medicaid Focus
Screening • Schizophrenia
• CAD Beta Blocker • Fraud
• Emphysema Advanced
• Cervical Cancer Therapy Imaging before Surgery Cardiovascular Dis
Screening • Administrative Monitoring
• Depression Drug • Low Back Pain Opiates
• Colorectal Cancer
Screen
Management
• Diabetes Care
160M+
not Routine
• Clinical
• AMI Cardiac Rehab
recommended post
• Schizophrenia Diabetes
Monitoring
• Body Mass Index
• Low Back Pain
Imaging Studies • High Risk Medication
Use In Elderly
claims audited
Discharge Assessment Adult
• CAD Statin Therapy
• Heart Failure Beta
Blocker Therapy • URI Tx wo Antibiotics last 4 years
Footnotes 1 Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med; 164:425, https://www.ncbi.nlm.nih.gov/pubmed/26785402. 2 Gonzales R, Steiner JF, Sande MA (1997). Antibiotic prescribing for adults with colds, upper respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA. 1997; 278 (11):901, http://jamanetwork.com/journals/jama/fullarticle/187334. 3 Gonzales R, Steiner JF, Lum A, Barrett PH Jr (1999). Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA. 1999;281(16):1512, http://jamanetwork.com/journals/jama/fullarticle/773477. 4 Evertsen J, Baumgardner DJ, Regnery A, Banerjee I. (2010).Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices. Prim Care Respir J. 2010; 19(3):237, http://www.medscape.com/medline/abstract/20490437. 5 Xu, k.T., et al. 2013. Over-prescribing of antibiotics and imaging in the management of uncomplicated URIs in emergency departments. BMC Emerg Med; 13:7. Doi: 10.1186/1471-227x-13-7, http://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-13-7. 6 NCQA State of Health Care Quality 2007, National Committee for Quality Assurance: Washington D.C., http://www.ncqa.org/about-ncqa. 7 File, Thomas M, Jr., MD, Acute bronchitis in adults, UpToDate, http://cursoenarm.net/UPTODATE/contents/mobipreview.htm?35/53/36688?source=see_link 8 The State of Health Care Quality Report, NCQA, http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2016-table-of-contents/acute-bronchitis. 9 NQF #0058 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis, Last Updated Date: Sep 25, 2012, NATIONAL QUALITY FORUM, Measure Submission and Evaluation Worksheet 5.0, www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=71543. 10 Respiratory tract infections (self-limiting): prescribing Antibiotics, Clinical guideline [CG69], NICE, Published date: July 2008, https://www.nice.org.uk/guidance/cg69/chapter/1-Guidance. 11 Bronchitis, Antibiotic Prescribing and Use in Doctor’s Offices, CDC (Centers for Disease Control and Prevention), https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/bronchitis.html.
Footnotes cont. 12 Janice L. Clarke, RN (2010). Preventive Medicine: A Ready Solution for a Health Care System in Crisis. Population Health Management. Volume 13, Supplement 2, 2010. DOI: 1089/pop.2010.1382, https://www.readbyqxmd.com/read/20879902/preventive-medicine-a-ready-solution-for-a-health-care-system-in-crisis 13 NCQA State of Health Care Quality 2007, National Committee for Quality Assurance: Washington, D.C., https://www.readbyqxmd.com/read/20879902/preventive-medicine-a-ready-solution-for-a-health-care-system-in-crisis. 14 Centers for Disease Control and Prevention. Chronic disease and health promotion. Retrieved from http://www.cdc.gov/chronicdisease/stats/index.htm on Jan. 24, 2014. 15 Medline ® Abstract for Reference 3 of 'Screening for colorectal cancer: Strategies in patients at average risk‘, UpToDate, https://www.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-average-risk/abstract/3 16 Medline ® Abstract for Reference 4 of 'Screening for colorectal cancer: Strategies in patients at average risk‘, UpToDate, https://www.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-average-risk/abstract/4 17 Medline ® Abstract for Reference 8 of 'Screening for colorectal cancer: Strategies in patients at average risk‘, UpToDate, https://www.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-average-risk/abstract/8
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