Kusserow on Compliance: CMS and Veterans Affairs partnering to address fraud and abuse

The Department of Veterans Affairs (VA) and CMS announced a partnership to share data, data analytics tools, and best practices for identifying and preventing fraud, waste, and abuse. The Veterans Health Administration is a large integrated health care system operated by the VA and has many issues already being addressed by CMS. Through the Veterans Health Administration, the VA is itself the provider, operating an integrated network of 168 medical centers, more than 1,000 outpatient clinics, 250 brick-and-mortar pharmacies, and seven mail-order pharmacies. The VA health system employs over 200,000 health care professionals and covers about nine million veterans in the US.

The new alliance is intended to enhance ongoing efforts between the country’s two largest public-private health-care payment organizations. This collaboration is intended to identify new and innovative ways to seek out fraud, waste, and abuse. CMS estimates that its program integrity activities saved Medicare operations $17 billion in fiscal 2015. Much of this arises from new practices and technologies that will now be shared with the VA, which will be able to capitalize on the advancements in analytics CMS has made and hopefully it will be able to close existing gaps in its own claims payment process. CMS also noted in its announcement that VA invited industry experts in November 2017 to provide information on the latest commercial sector tools and techniques to enhance VA’s fraud detection capabilities.


Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.

IBM poised to conquer health data analytics with Truven acquisition

IBM entered into a $2.6 billion agreement to buy Truven Health Analytics, a provider of cloud-based health care data that informs benefit decisions for one in three Americans. The purchase will bring more than 8,500 clients to IBM’s Watson Health portfolio, including  federal and state government agencies, employers, health plans, hospitals, clinicians and life sciences companies. The acquisition will make IBM one of the world’s leading data, analytics, and insight companies.

This will be IBM’s fourth major health-related acquisition since launching Watson Health in April 2015, following acquisitions of Phytel (population health), Explorys (cloud-based health care intelligence), and Merge Healthcare (medical imaging).

How can large amounts of data improve care?

The increasing prevalence of value-based care under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) necessitates the use of large amounts of data to drive the improvement of health outcomes for patients at lower costs. In order for data analytics to work, providers, payers, and other stakeholders must document how specific elements of care contribute to achieving a certain health outcome at a given cost. The increasing complexity of the health industry, paired with the government’s focus on improving the quality and lowering the cost of care, requires health care providers to make smarter, more informed decisions.

Consumers also expect more access to information and increased accountability from their doctors, nurses, and health plans, so providers are turning to big data and predictive analysis to improve patient care and control costs.

Data analytics is “the systematic use of data and related business insights developed through applied analytical disciplines (e.g., statistical, contextual, quantitative, predictive, cognitive, and [other models]) to drive fact-based decision making for planning, management, measurement, and learning,” according to a report by IBM. Analytics may be used to describe trends, predict outcomes, or prescribe actions. In health care, data analytics can help providers observe trends in both the patient’s own medical record, as well as records of patients with similar histories, to predict an individual patient’s level of risk for a given medical outcome. Doing so can help to avoid erroneous diagnoses and unnecessary procedures and aid in the provision of more individualized care.

IBM’s robust aggregation of data

IBM showed in a report detailing the use of analytics in health care that top performers in health care (self-identified as outperforming health care organizations) are focused on ramping up their analytics capabilities, with more than 90 percent of health care chief information officers (CIOs) for top-performing organizations citing insight and intelligence as a key focus for their organizations, compared to 65 percent of underperformers in the industry. Increased business intelligence and analytics was also cited as the top priority of 83 percent of health care CIOs when asked about plans to increase competitiveness.

IBM’s purchase of Truven Health Analytics is expected to close later in the year, once applicable regulatory reviews have finished. Once completed, IBM will be in possession of one of the world’s largest and most diverse collections of health-related data, which would represent an aggregate of 300 million patients worth of data. This robust aggregation of data includes information on costs, claims, quality, and outcomes, the analysis of which can create unique insights to help aid in making health care decisions.