Co-Morbidities and Using Data to Manage Population Health

Managing the quality and cost of co-morbid populations is one of the most challenging aspects of health leadership. In this Discussion, you are challenged with selecting those data which will be most helpful in the management of Medicare populations. As health information exchanges (HIEs) progress at the state, federal, and nation level, health leaders are tasked to participate in the development of analytics tools that can be used to pull data and inform policy practice.Scenario: Review the high volume Medicare Data Scenario located in the Learning Resources. In this scenario you are asked to work with a complex dataset of co-morbidity data of patients that have three concurrent co-morbid conditions (Chronic Condition Triads: Prevalence and Medicare Spending). How can data from HIT systems be used to formulate useful information to facilitate in the management of this population?To prepare:Using the health care information systems standards for clinical and financial data discussed in Week 6 (Chapter 11 of Health Care Information Systems: A Practical Approach for Health Care Management), identify specific types of data (data sets, standards, examples of those data) that can be redeveloped into Big Data tools and used to address the management of population health initiatives.Define a “Big Data” analysis dataset to include in a data warehouse by identifying two specific types of clinical and financial data from the Chronic Condition Triads: Prevalence and Medicare Spending dataset in your Learning Resources that you feel could be used to drive behavior change in the patient and provider populations. This Big Data dataset will become the focus of your Discussion.Post:Explain why the two specific types of clinical and financial data you selected as your Big Data dataset would best affect behavior change in the type of co-morbid Medicare populations served in the scenario. Explain and assess how this Big Data dataset can change the behaviors of health care providers in the scenario. Assuming that your Big Data dataset is going to be shared in a regional health information exchange, explain how the Centers for Medicare and Medicaid Services and private payers might use these regional data sets to increase value in delivering services to co-morbid Medicare patient populations in the region.
usw1_mmha_6600_week07_chronicconditiontriads.xlsx

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Chronic Condition Triads: Prevalence and Medicare Spending
Methods
Data Source and Study Population: The data used in the chronic condition reports are based upon CMS
administrative enrollment and claims data for Medicare beneficiaries enrolled in the fee-for-service program.
These data are available from the CMS Chronic Condition Data Warehouse (CCW), www.ccwdata.org. For all the
chronic condition reports the Medicare beneficiary population is limited to fee-for-service beneficiaries. We
excluded Medicare beneficiaries with any Medicare Advantage enrollment during the year since claims data are
not available for these beneficiaries. Also, we excluded beneficiaries who were enrolled at any time in the year in
Part A only or Part B only, since their utilization and spending cannot be compared directly to beneficiaries
enrolled in both Part A and Part B. Beneficiaries who died during the year are included up to their date of death
if they meet the other inclusion criteria. For chronic condition triads, the population is further restricted to
beneficiaries who have at least three of the 17 conditions.
Data Years: 2008–2012
Chronic Condition Co-morbidity: The 17 chronic conditions were identified through Medicare administrative
claims. A Medicare beneficiary is considered to have a chronic condition if the CMS administrative data have a
claim indicating that the beneficiary received a service or treatment for the specific condition. Detailed
information on the identification of chronic conditions in the CCW is available at
http://www.ccwdata.org/chronic-conditions/index.htm. Chronic condition triads represent the combinations of
three chronic conditions among Medicare beneficiaries who have at least three of the conditions. There are 680
triads.
Socio-demographic Variables: A beneficiary’s sex is available from the CMS enrollment database and is
classified as Male/Female. Beneficiaries enrolled in both Medicare and Medicaid are known as “dual eligibles.”
Medicare beneficiaries were classified as dual eligibles if in any month in the given calendar year they were
receiving full or partial Medicaid benefits.
Measures: Prevalence estimates are calculated by taking the beneficiaries with a particular chronic condition
triad divided by the total number of beneficiaries in our fee-for-service population, expressed as a percentage.
Medicare spending for beneficiaries with the chronic condition triad includes total Medicare payments for all
Medicare covered services in Parts A and B and is presented per beneficiary (i.e., per capita).
Data Suppression: A blank cell indicates that the data have been suppressed because there are fewer than 11
Medicare beneficiaries in the cell.
Methodology Report: A complete description of the methodology for all the chronic condition reports can be
downloaded from the link available on the chronic condition website main page.
Chronic Condition Triads: All Beneficiaries with at least Three Chronic Conditions by A
Alzheimer’s Disease/Dementia and COPD and Diabetes
Alzheimer’s Disease/Dementia and COPD and Heart Failure
Alzheimer’s Disease/Dementia and COPD and Cancer
Alzheimer’s Disease/Dementia and COPD and Chronic Kidney Disease
Alzheimer’s Disease/Dementia and COPD and Depression
Alzheimer’s Disease/Dementia and COPD and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and COPD and Osteoporosis
Alzheimer’s Disease/Dementia and COPD and Arthritis
Alzheimer’s Disease/Dementia and COPD and Stroke
Alzheimer’s Disease/Dementia and COPD and Atrial Fibrillation
Alzheimer’s Disease/Dementia and COPD and Asthma
Alzheimer’s Disease/Dementia and COPD and Hyperlipidemia
Alzheimer’s Disease/Dementia and COPD and Hypertension
Alzheimer’s Disease/Dementia and COPD and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and COPD and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Diabetes and Heart Failure
Alzheimer’s Disease/Dementia and Diabetes and Cancer
Alzheimer’s Disease/Dementia and Diabetes and Chronic Kidney Disease
Alzheimer’s Disease/Dementia and Diabetes and Depression
Alzheimer’s Disease/Dementia and Diabetes and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and Diabetes and Osteoporosis
Alzheimer’s Disease/Dementia and Diabetes and Arthritis
Alzheimer’s Disease/Dementia and Diabetes and Stroke
Alzheimer’s Disease/Dementia and Diabetes and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Diabetes and Asthma
Alzheimer’s Disease/Dementia and Diabetes and Hyperlipidemia
Alzheimer’s Disease/Dementia and Diabetes and Hypertension
Alzheimer’s Disease/Dementia and Diabetes and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Diabetes and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Heart Failure and Cancer
Alzheimer’s Disease/Dementia and Heart Failure and Chronic Kidney Disease
Alzheimer’s Disease/Dementia and Heart Failure and Depression
Alzheimer’s Disease/Dementia and Heart Failure and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and Heart Failure and Osteoporosis
Alzheimer’s Disease/Dementia and Heart Failure and Arthritis
Alzheimer’s Disease/Dementia and Heart Failure and Stroke
Alzheimer’s Disease/Dementia and Heart Failure and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Heart Failure and Asthma
Alzheimer’s Disease/Dementia and Heart Failure and Hyperlipidemia
Alzheimer’s Disease/Dementia and Heart Failure and Hypertension
Alzheimer’s Disease/Dementia and Heart Failure and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Heart Failure and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Cancer and Chronic Kidney Disease
Alzheimer’s Disease/Dementia and Cancer and Depression
Alzheimer’s Disease/Dementia and Cancer and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and Cancer and Osteoporosis
Alzheimer’s Disease/Dementia and Cancer and Arthritis
Alzheimer’s Disease/Dementia and Cancer and Stroke
Alzheimer’s Disease/Dementia and Cancer and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Cancer and Asthma
Alzheimer’s Disease/Dementia and Cancer and Hyperlipidemia
Alzheimer’s Disease/Dementia and Cancer and Hypertension
Alzheimer’s Disease/Dementia and Cancer and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Cancer and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Depression
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Osteoporosis
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Arthritis
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Stroke
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Asthma
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Hyperlipidemia
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Hypertension
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Chronic Kidney Disease and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Depression and Ischemic Heart Disease
Alzheimer’s Disease/Dementia and Depression and Osteoporosis
Alzheimer’s Disease/Dementia and Depression and Arthritis
Alzheimer’s Disease/Dementia and Depression and Stroke
Alzheimer’s Disease/Dementia and Depression and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Depression and Asthma
Alzheimer’s Disease/Dementia and Depression and Hyperlipidemia
Alzheimer’s Disease/Dementia and Depression and Hypertension
Alzheimer’s Disease/Dementia and Depression and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Depression and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Osteoporosis
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Arthritis
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Stroke
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Asthma
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Hyperlipidemia
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Hypertension
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Ischemic Heart Disease and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Osteoporosis and Arthritis
Alzheimer’s Disease/Dementia and Osteoporosis and Stroke
Alzheimer’s Disease/Dementia and Osteoporosis and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Osteoporosis and Asthma
Alzheimer’s Disease/Dementia and Osteoporosis and Hyperlipidemia
Alzheimer’s Disease/Dementia and Osteoporosis and Hypertension
Alzheimer’s Disease/Dementia and Osteoporosis and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Osteoporosis and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Arthritis and Stroke
Alzheimer’s Disease/Dementia and Arthritis and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Arthritis and Asthma
Alzheimer’s Disease/Dementia and Arthritis and Hyperlipidemia
Alzheimer’s Disease/Dementia and Arthritis and Hypertension
Alzheimer’s Disease/Dementia and Arthritis and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Arthritis and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Stroke and Atrial Fibrillation
Alzheimer’s Disease/Dementia and Stroke and Asthma
Alzheimer’s Disease/Dementia and Stroke and Hyperlipidemia
Alzheimer’s Disease/Dementia and Stroke and Hypertension
Alzheimer’s Disease/Dementia and Stroke and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Stroke and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Atrial Fibrillation and Asthma
Alzheimer’s Disease/Dementia and Atrial Fibrillation and Hyperlipidemia
Alzheimer’s Disease/Dementia and Atrial Fibrillation and Hypertension
Alzheimer’s Disease/Dementia and Atrial Fibrillation and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Atrial Fibrillation and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Asthma and Hyperlipidemia
Alzheimer’s Disease/Dementia and Asthma and Hypertension
Alzheimer’s Disease/Dementia and Asthma and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Asthma and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Hyperlipidemia and Hypertension
Alzheimer’s Disease/Dementia and Hyperlipidemia and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Hyperlipidemia and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Hypertension and Autism Spectrum Disorders
Alzheimer’s Disease/Dementia and Hypertension and Schizophrenia and Other Psychotic Disorders
Alzheimer’s Disease/Dementia and Autism Spectrum Disorders and Schizophrenia and Other Psychotic Disorders
COPD and Diabetes and Heart Failure
COPD and Diabetes and Cancer
COPD and Diabetes and Chronic Kidney Disease
COPD and Diabetes and Depression
COPD and Diabetes and Ischemic Heart Disease
COPD and Diabetes and Osteoporosis
COPD and Diabetes and Arthritis
COPD and Diabetes and Stroke
COPD and Diabetes and Atrial Fibrillation
COPD and Diabetes and Asthma
COPD and Diabetes and Hyperlipidemia
COPD and Diabetes and Hypertension
COPD and Diabetes and Autism Spectrum Disorders
COPD and Diabetes and Schizophrenia and Other Psychotic Disorders
COPD and Heart Failure and Cancer
COPD and Heart Failure and Chronic Kidney Disease
COPD and Heart Failure and Depression
COPD and Heart Failure and Ischemic Heart Disease
COPD and Heart Failure and Osteoporosis
COPD and Heart Failure and Arthritis
COPD and Heart Failure and Stroke
COPD and Heart Failure and Atrial Fibrillation
COPD and Heart Failure and Asthma
COPD and Heart Failure and Hyperlipidemia
COPD and Heart Failure and Hypertension
COPD and Heart Failure and Autism Spectrum Disorders
COPD and Heart Failure and Schizophrenia and Other Psychotic Disorders
COPD and Cancer and Chronic Kidney Disease
COPD and Cancer and Depression
COPD and Cancer and Ischemic Heart Disease
COPD and Cancer and Osteoporosis
COPD and Cancer and Arthritis
COPD and Cancer and Stroke
COPD and Cancer and Atrial Fibrillation
COPD and Cancer and Asthma
COPD and Cancer and Hyperlipidemia
COPD and Cancer and Hypertension
COPD and Cancer and Autism Spectrum Disorders
COPD and Cancer and Schizophrenia and Other Psychotic Disorders
COPD and Chronic Kidney Disease and Depression
COPD and Chronic Kidney Disease and Ischemic Heart Disease
COPD and Chronic Kidney Disease and Osteoporosis
COPD and Chronic Kidney Disease and Arthritis
COPD and Chronic Kidney Disease and Stroke
COPD and Chronic Kidney Disease and Atrial Fibrillation
COPD and Chronic Kidney Disease and Asthma
COPD and Chronic Kidney Disease and Hyperlipidemia
COPD and Chronic Kidney Disease and Hypertension
COPD and Chronic Kidney Disease and Autism Spectrum Disorders
COPD and Chronic Kidney Disease and Schizophrenia and Other Psychotic Disorders
COPD and Depression and Ischemic Heart Disease
COPD and Depression and Osteoporosis
COPD and Depression and Arthritis
COPD and Depression and Stroke
COPD and Depression and Atrial Fibrillation
COPD and Depression and Asthma
COPD and Depression and Hyperlipidemia
COPD and Depression and Hypertension
COPD and Depression and Autism Spectrum Disorders
COPD and Depression and Schizophrenia and Other Psychotic Disorders
COPD and Ischemic Heart Disease and Osteoporosis
COPD and Ischemic Heart Disease and Arthritis
COPD and Ischemic Heart Disease and Stroke
COPD and Ischemic Heart Disease and Atrial Fibrillation
COPD and Ischemic Heart Disease and Asthma
COPD and Ischemic Heart Disease and Hyperlipidemia
COPD and Ischemic Heart Disease and Hypertension
COPD and Ischemic Heart Disease and Autism Spectrum Disorders
COPD and Ischemic Heart Disease and Schizophrenia and Other Psychotic Disorders
COPD and Osteoporosis and Arthritis
COPD and Osteoporosis and Stroke
COPD and Osteoporosis and Atrial Fibrillation
COPD and Osteoporosis and Asthma
COPD and Osteoporosis and Hyperlipidemia
COPD and Osteoporosis and Hypertension
COPD and Osteoporosis and Autism Spectrum Disorders
COPD and Osteoporosis and Schizophrenia and Other Psychotic Disorders
COPD and Arthritis and Stroke
COPD and Arthritis and Atrial Fibrillation
COPD and Arthritis and Asthma
COPD and Arthritis and Hyperlipidemia
COPD and Arthritis and Hypertension
COPD and Arthritis and Autism Spectrum Disorders
COPD and Arthritis and Schizophrenia and Other Psychotic Disorders
COPD and Stroke and Atrial Fibrillation
COPD and Stroke and Asthma
COPD and Stroke and Hyperlipidemia
COPD and Stroke and Hypertension
COPD and Stroke and Autism Spectrum Disorders
COPD and Stroke and Schizophrenia and Other Psychotic Disorders
COPD and Atrial Fibrillation and Asthma
COPD and Atrial Fibrillation and Hyperlipidemia
COPD and Atrial Fibrillation and Hypertension
COPD and Atrial Fibrillation and Autism Spectrum Disorders
COPD and Atrial Fibrillation and Schizophrenia and Other Psychotic Disorders
COPD and Asthma and Hyperlipidemia
COPD and Asthma and Hypertension
COPD and Asthma and Autism Spectrum Disorders
COPD and Asthma and Schizophrenia and Other Psychotic Disorders
COPD and Hyperlipidemia and Hypertension
COPD and Hyperlipidemia and Autism Spectrum Disorders
COPD and Hyperlipidemia and Schizophrenia and Other Psychotic Disorders
COPD and Hypertension and Autism Spectrum Disorders
COPD and Hypertension and Schizophrenia and Other Psychotic Disorders
COPD and Autism Spectrum Disorders and Schizophrenia and Other Psychotic Disorders
Diabetes and Heart Failure and Cancer
Diabetes and Heart Failure and Chronic Kidney Disease
Diabetes and Heart Failure and Depression
Diabetes and Heart Failure and Ischemic Heart Disease
Diabetes and Heart Failure and Osteoporosis
Diabetes and Heart Failure and Arthritis
Diabetes and Heart Failure and Stroke
Diabetes and Heart Failure and Atrial Fibrillation
Diabetes and Heart Failure and Asthma
Diabetes and Heart Failure and Hyperlipidemia
Diabetes and Heart Failure and Hypertension
Diabetes and Heart Failure and Autism Spectrum Disorders
Diabetes and Heart Failure and Schizophrenia and Other Psychotic Disorders
Diabetes and Cancer and Chronic Kidney Disease
Diabetes and Cancer and Depression
Diabetes and Cancer and Ischemic Heart Disease
Diabetes and Cancer and Osteoporosis
Diabetes and Cancer and Arthritis
Diabetes and Cancer and Stroke
Diabetes and Cancer and Atrial Fibrillation
Diabetes and Cancer and Asthma
Diabetes and Cancer and Hyperlipidemia
Diabetes and Cancer and Hypertension
Diabetes and Cancer and Autism Spectrum Disorders
Diabetes and Cancer and Schizophrenia and Other Psychotic Disorders
Diabetes and Chronic Kidney Disease and Depression
Diabetes and Chronic Kidney Disease and Ischemic Heart Disease
Diabetes and Chronic Kidney Disease and Osteoporosis
Diabetes and Chronic Kidney Disease and Arthritis
Diabetes and Chronic Kidney Disease and Stroke
Diabetes and Chronic Kidney Disease and Atrial Fibrillation
Diabetes and Chronic Kidney Disease and Asthma
Diabetes and Chronic Kidney Disease and Hyperlipidemia
Diabetes and Chronic Kidney Disease and Hypertension
Diabetes and Chronic Kidney Disease and Autism Spectrum Disorders
Diabetes and Chronic Kidney Disease and Schizophrenia and Other Psychotic Disorders
Diabetes and Depression and Ischemic Heart Disease
Diabetes and Depression and Osteoporosis
Diabetes and Depression and Arthritis
Diabetes and Depression and Stroke
Diabetes and Depression and Atrial Fibrillation
Diabetes and Depression and Asthma
Diabetes and Depression and Hyperlipidemia
Diabetes and Depression and Hypertension
Diabetes and Depression and Autism Spectrum Disorders
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Diabetes and Ischemic Heart Disease and Osteoporosis
Diabetes and Ischemic Heart Disease and Arthritis
Diabetes and Ischemic Heart Disease and Stroke
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Diabetes and Ischemic Heart Disease and Hyperlipidemia
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Diabetes and Osteoporosis and Asthma
Diabetes and Osteoporosis and Hyperlipidemia
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