Data analytics are playing a major role in treating chronically ill patients, the American Medical
Group Association has told members of the Senate Finance Committee’s chronic care workgroup.

The workgroup is asking stakeholders for information and recommendations as it considers making changes to the Medicare program to better service chronic populations. AMGA, which represents multi-specialty practices and integrated delivery systems, in a letter to the workgroup explained how IT supports care management processes.

“Effective care management processes begin with an ability to identify and risk-stratify patients with multiple chronic conditions,” the association said. “Clinical data is derived from medical group EHR systems and combined, when possible, with administrative claims data.”

Analyzing the data gives providers a clear picture of patients, helps discover utilization and outcomes trends, and guides interventions to the best treatment. “This data is used in real time within the hospital setting to identify patients in need of more comprehensive discharge planning which may include a higher level of medication reconciliation, timely primary care follow-up and provision of in-home or community-based services.”

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Predictive analytics give insight into patients most at risk for a hospital or emergency department admission within the next six months, AMGA told the workgroup. But there remain major challenges as the technology and staff needed for an infrastructure that identifies and cares for the chronically ill is enormous.

“Functions, data definitions and clinical activities must be standardized and integrated into the IT and provider workflows across the system,” the association noted. “EHR fields must be developed to capture data, data from many systems must be integrated, dashboards must be built to demonstrate care gaps and performance, and consistent education and support teams must be in place.”

AMGA members in the letter also explained the importance of supporting programs such as outpatient healthcare navigators, inpatient care managers, behavioral health integration with other services and impediments to care—one of which is that care management efforts largely are not reimbursed under Medicare.

“Consequently, to design a system that rewards value and incents the care of the chronically ill, Congress must offer providers the financial and operational tools necessary for success in managing populations of patients,” states the letter. “Such tools include financial support for care management infrastructure, timely access to all claims data, full cost and quality transparency, actionable data exchange, clear attestation models, and patient engagement and accountability.”

Without these tools, there is little incentive to manage chronic populations, the association warned. The complete letter is available here.

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