Nura Health Media

Transforming Healthcare Requires a New IT Framework

by Wayne H. Miller, CEO of Nura Health

The State of the Healthcare Ecosystem

Renowned management consultant Peter Drucker once said, "Without data, it doesn't exist." When one examines the American system of healthcare, the wisdom of Drucker's statement is abundantly clear.

The healthcare system of the US has been built using a data capture IT platform that has three fundamental variables. First, it records what doctors do to patients, i.e. the procedures performed as the "care." Second, it characterizes those procedures on the basis of two attributes: (1) how much time did it take for the doctor to do it and (2) how much training did it take for the doctor to know how to do it. Third, it captures whether the procedure was done in an office/hospital or an urban/rural setting. These attributes are then used in a formula to determine how much the doctor is paid for delivering those services. There is no element of this data-capture and classification system that addresses the question: how well did that procedure work to resolve the patient's problem(s). In fact, the efficacy of the procedure is not considered whatsoever in the algorithms that determine the payment made to the doctor for the service(s) delivered.

There are approximately 12,000 numerical codes in the Healthcare Common Procedure Coding System ("HCPCS") used to identify these services. In the almost 50 years since the creation of Medicare, rules have evolved that have guided the development, administration and operations of Medicare and Medicaid as well as commercial healthcare insurance operations. All of these business processes, now embedded in the healthcare delivery and payment infrastructure, have been derived from the information represented in (or missing from) the HCPCS coding system (or its predecessor). Literally, over a couple of generations, how we have come to think about healthcare has been developed and reinforced by countless human behaviors derived from the design and architecture of this data gathering system - all of which missed the important element of treatment efficacy.

The Problem – it's all about data

The financial algorithms embedded in HCPCS and the formulas used to determine payments to doctors are adjudicated annually by a few dozen medical specialists (those with advanced training and in receipt of substantial income under the existing HCPCS system). Their recommendations to Medicare, in spite of the conflicts-of-interest embedded in their advice, are accepted >90% of the time.

The financial algorithms embedded in HCPCS and the formulas used to determine payments to doctors are adjudicated annually by a few dozen medical specialists (those with advanced training and in receipt of substantial income under the existing HCPCS system). Their recommendations to Medicare, in spite of the conflicts-of-interest embedded in their advice, are accepted >90% of the time.

By contrast, physicians who practice Integrative Medicine (using a holistic multi-disciplinary approach to patient care) as well as the 2 million other allied healthcare professionals whose activities are not represented in the HCPCS system operate clinical practices in which procedural data is rarely captured and never properly classified. Without recording the activity of these licensed professionals, the efficacy of their activities, either individually or collectively, is not consistently measured, reported or recognized. However, broad based research on Integrative Medicine Best Practices (pdf) conducted at 52 major academic centers, indicate that the Integrative Medicine approach to patient care is particularly valuable when it comes to treating those with one or more chronic diseases. Around 150 million Americans have been diagnosed with one chronic disease – 50 million with three or more.

Comparative effectiveness analysis between conventional vs. Integrative Medicine patient care and financial analysis of the cost-effectiveness of Integrative Medicine care is not possible without a mechanism to capture procedural data in a large population setting. This means that the people responsible for paying for healthcare, particularly the finance officers of large employers offering health benefits to their employees, have no IT tools, no quantitative framework, and no visibility they can use to drive efficiency and value for their healthcare spending.

Until now

The Solution – it's all about data

Nura Health offers an IT platform that can lead to a coherent analysis of how to best allocate funds for chronic healthcare services. This will create substantial value for all Self Insured Payors (major employer health plans), whether public or private entities. The analysis begins with using an Economic Value Added like lens and examining a program in which the "Best Practices" of Integrative Medicine practitioners are captured by a procedural coding system specifically designed to do so. This is possible because the Nura's Platform contains detailed IM procedure codes not represented in the HCPCS system - about 4,500 of them.

How important is this? In the HCPCS system there are less than a dozen codes to capture the activity of nursing and specialty nursing professionals. In Nura's Platform there are 800. Furthermore, Nura's IT platform validates that clinicians who use an Integrative Medicine approach to patient care comply with various national and state scope of practice regulations. This is essential for HIPPA compliance purposes. In addition, the use of non-patented clinical methods and strategies can be documented and subject to the comparative effectiveness assessment. Once it is known what is done to a patient and what type of clinician did it, the quality of the patient outcomes, however they are measured, can be contrasted to the outcomes associated with more conventional (standard of care procedures codified in the HCPCS system).

The Nura Platform builds a database to validate and quantify the protocols that work. The architecture of the Nura Platform enables Nura to feed back out into the community of IM practitioners (the Nura Provider Network), the data that implies a particularly high level of efficacy for any given protocol. The community can then refine that protocol and in so doing the Nura Platform becomes a tool which turns the care delivery system into a learning machine. Such a design exemplifies data-driven "continuous process improvement," one of the bedrock principles upon which Nura Health was built. That Value nourishes the entire healthcare ecosystem.

The components of the Nura Platform have been beta-tested and meets the national and international design standards required for the electronic filing of medical claims. Once a self-funded payor initiates a demonstration project to collect IM clinical data, they will start to pave the way for a credible analysis of comparative effectiveness between IM and conventional care. With that assessment they will be empowered to make more effective capital allocation decisions as they pay for healthcare benefits.

The Nura Platform, is the foundation for a value-based healthcare payment system that allocates capital efficiently and promotes quality in chronic healthcare services.

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