The Elusive Site of Care

Imagine conducting a market assessment of how your organization's orthopedic service line compares to the competition. You can see the volume of orthopedic procedures and maybe the practitioners associated with those procedures, but you have a blindspot in the location where the procedures were performed. Or you are a Life Sciences company putting together a launch plan targeting the most relevant practitioners. The problem is you can't tell which practitioner location you should focus on from the data. These are common drawbacks associated with healthcare data sources that do not include the site of care. So, how can you fill in these gaps in visibility?

Why Site of Care is Important

The site of care (the actual location where patient care is rendered) is an important factor in many strategic activities for Healthcare and Life Sciences organizations, including:

  • Identifying Trends
  • Conducting Market Intelligence
  • Understanding Physician-to-Facility Affiliation
  • Supporting Sales
  • Assessing Mergers and Acquisitions
  • Building Alliances
  • Discovering Network Options
  • Correcting Missed Opportunities and Leakage
  • Physician Targeting and Launch Plans
  • Pricing and Reimbursement Decisions

Site of care is important when health plans use care optimization strategies to reduce costs, for example. When considering a site of care, health plans may prefer a provider's office or an ambulatory care center over a hospital setting for some procedures because those facilities are generally less costly. Site of care is also an important consideration for pricing and reimbursement direction. For example, due to lower costs, health plans may direct the administration of specific specialty biologic medications to an infusion center rather than to an institutional setting.

Despite its vital importance, many healthcare data vendors cannot provide a granular level of detail for sites of care, making it difficult to get a deep and accurate understanding of the market and patient/provider behavior. Determining the correct site of care requires subject matter expertise (to understand claims data and their strengths and weaknesses) and data science techniques (to correct errors).

Why the Difficulty?

Several factors complicate site of care accuracy that we will discuss; however, it is critical to understand two elements of a claim that indicate the setting and place where services were rendered: Place of Service (POS) and Bill Type Code. POS codes are found on provider claims, and Bill Type Codes (which identify Type of Facility) are found on institutional claims.

The Centers for Medicare & Medicaid Services (CMS) has designated POS codes to indicate the setting of care where a service is provided, like an Ambulatory Surgery Center (ASC), Acute Inpatient Hospital, Imaging Center, Physician Office and dozens of other care settings. Why are POS codes required to be submitted from the provider? Claims are a reimbursement mechanism, and each POS has a specific allowable reimbursement amount. So, the specific, accurate address where services were rendered has little bearing on reimbursement. Providers must identify the POS on a claim to ensure appropriate reimbursement, and the code should be compatible with the procedure performed in that care setting. 

While a POS indicates a type of setting, the "site of care" is the specific location where care was delivered. It may be tempting to use POS as an analog for site of care. But doing that will likely lead you to reach inaccurate conclusions.

Here is a specific example of how to think about this.

Individual A, let's call her Jamie Jones, had her carpal tunnel procedure at the Westside Orthopedic Ambulatory Surgery Center. Under her health plan, Jamie's payer insists these services be rendered at an ASC. In this case, there needs to be either an ASC indicator in the bill type code if it is an institutional claim or an ASC indicator in the POS field if it is a professional claim. There may also be an address listed on the claim, but it may not be for Westside Ambulatory Surgery Center; it could be for their billing office in another town. Suppose you were to download this data and assume this address indicates the actual location where the surgery was performed, aka the site of care. In that case, you might be led astray when calculating patient migration patterns, for example.

When you dive deeper, this example can get even more complicated. Suppose Jamie had a follow-up visit at her physician's office two weeks after surgery. Claims often have indicators or modifiers providing more granular details about the encounter. In Jamie's case, the Ambulatory Surgery bill had an ASC POS code and a modifier showing "follow-up" as the visit reason. This data indicates that reimbursement for the claim should occur at her plan's negotiated rate for ASCs. But, the data does not tell you whether Jamie received her follow-up visit at her physician's office or whether her follow-up visit was at the same location where she had her surgery. Complicated, we know! That is why using claims data, especially claims submission data, without correcting for site of care can be misleading and not provide a complete, accurate picture.

How we Approach the Problem

Kythera has spent years applying subject matter expertise and data science to claims data to reveal more accurate sites of care. Using our database of over 338 million unique patients, including inpatient, outpatient, and provider visits; testing and imaging; ancillary services; prescription fills; and telehealth claims, we have designed solutions that take a real-world approach to data analysis for more accurate results. The key is not being satisfied with seeing an ASC POS Code on the claim and assuming the care took place at an ASC or seeing an address on a claim and assuming it is the accurate site of care. 

We have discussed why assigning an accurate site of care is not as easy as it may appear. Simply using an address will not give us a confident site of care assignment. An address is a unique location, such as 256 Locust Drive, Mayville, TX, which may be the address for a hospital campus. On this campus, at this address, there is also an imaging center, a hospital, and a physician's office building. While there may be one address on a claim, assigning the correct site of care requires appending metadata from the claim and reference data to complete the assignment.

To improve the accuracy and reliability of site of care, we built an advanced facility directory and statistical model that consider reference data provided by CMS, like Physician Compare and NPPES, along with other sources. We also standardize all addresses submitted on a claim, assign a latitude and longitude, and consider other claims data elements like:

  • Diagnosis
  • Procedure
  • Facility-type taxonomy
  • Type 2 NPI
  • Physician specialty
  • Type of care rendered

The model then compares the result to our facility directory to ensure it makes business sense. 

Precision Targeting is Possible

Despite the difficulties associated with raw claims data, Kythera's data science methodologies and remastered data can fill in the gaps, making claims data more accurate and usable. With improved data accuracy, you can create strategies with more confidence and better outcomes. Get in touch if you'd like to talk with us about our site of care methodologies or metrics:

Is Site of Care Still Relevant?
In the increasingly digital and virtual world of healthcare delivery, the location of care could be anywhere. When a patient and provider can be on the other side of the world and have a detailed conversation - does the location of an office visit matter anymore? 
We think that certain healthcare encounters benefit tremendously from innovations like telehealth and can be delivered without the practitioner and the patient sharing a physical location. However, most of the care delivered to a patient still requires the touch of a professional caregiver, for example, changing wound coverings, surgical interventions, injections of a pharmaceutical, and for the patient and provider to be in the same physical space. Because of this, we believe the physical location known as site of care is still and will continue to be important in understanding the patient journey and market conditions.

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Grant Stubblefield

Director of Product

Grant is a Product Management leader at Kythera Labs, focusing on developing products that deliver insights from public and private data. Having supported 30+ US payers to solve challenges in claims adjudication, member enrollment, and provider data management, Grant has deep experience and understanding of the technical challenges facing the Healthcare industry.
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