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Applications of Transparency:
From Visibility to ActionAs transparency in health care has emerged as a crucial enabler towards achieving the Triple Aim, myriad sources and types of information have become available in the last few years. Join this session to learn new ways of understanding the behaviors of patients and providers, and novel approaches to payment and delivery already underway.
Moderator: Ben Harder, U.S. News & World Report
Panelists: Elizabeth Mitchell, NRHI;
Jeanne Pinder, ClearHealthCosts;
Josh Rosenthal, PhD, RowdMap, Inc.
Unexpected Transparency:
Underserved Populations,
Unwarranted Variation and
Unnecessary Spend
How valuable is a doctor to a population?
Which doctors start with higher intensity options? Which will succeed in Pay for Value?
Which doctors create the most no-value care and unnecessary spend?
This is different than ranking docs by cost of drugs or treatment, or the basics of care and operations.
Another way to think about it
What do my rankings measure?
How much an antibiotic costs?
How nice the doctor’s office is while waiting for the antibiotic?
Or…
Whether the doctor should have started with the antibiotic out of the gate in the first place?
David Wennberg,RowdMap Advisory Board
Open Data Is Powerful, DisruptiveOutperforms claims-based models for risk adjustment
New Government Released Referral Data(Patient flows between PCPS, specialists, hospitals and post acute centers)
Dartmouth Atlas for Unwarranted Variation(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons, hence “Unwarranted” in the name)
New Government Released Performance Data (Individual providers, groups, hospitals and post acute centers including the new part B&D)
Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT.
Incredibly Meaningful RankingsParticularly powerful when pulled together
Affordable Care Act data to determine Risk-Readiness of Providers / Networks
The business context has changed- health plans, government payers, providers, and hospital systems need
to develop Risk-Readiness SM strategies to excel as they transition from fee-for-service to pay-for value.
CMS: 50% of FFS will be gone by 2018
Current payment models aren’t changing provider behavior. Providers need help. Effects of Health Care Payment Models on
Physician Practice in the United States, May 2015.
Featured NationallyUS CTO on RowdMap: “Visionary
Genius”
Chronic prevalence & physician supplyPopulation Health ReportPopulation Report Card
Match practice patterns to the right risk arrangements – Pay for Value ReadinessGroup Risk-Readiness SM ReportPhysician Risk-Readiness SM ReportHospital Risk-Readiness SM ReportPost Acute Center Risk-Readiness SM ReportRisk-Readiness SM Arrangement Match-Maker
Manage clinical care and costs – Remove No Value CareGroup Unnecessary Cost ReportPhysician Unnecessary Cost ReportHospital Unnecessary Cost ReportPost Acute Center Unnecessary Cost ReportUnnecessary Cost Referral and Value Chain Report
Unexpected Transparency:Underserved Populations, Unwarranted Variation and Unnecessary Spend
Chronic Prevalence &Physician Supply
Match Practice Patterns to the right Risk Arrangements – Pay for Value Readiness
Manage Clinical Care and Costs – Remove No Value Care
Unexpected Transparency:Underserved Populations, Unwarranted Variation and Unnecessary Spend
Diabetes Prevalence - Westchester
Use this data to allocate providers and care management resources around condition-specific population needs by zip.
Locate clinics, health fairs, etc. based on chronic needs.
Income
Obesity
Depression
Health Opportunity IndexLots of diabetics
but few PCPs
Lots of diabetics and lots of PCPs
What type of populations?
Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LE CDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisT Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxk
PCP Density –Westchester
Demand and Supply
12
County ProfilesLargest Counties In Ohio
People use this data to calibrate expectations for profitability by incorporating population health and provider performance into
product strategy. Use excess to subsidize operations in counties with fewer high-performing resources
Risk Scores Total CostPMPM
Reimbursement Overall Star Chronic Star Health Rank
MA Profit Opportunity -
MA
Profit Opportunity -
Exchange
MA Eligibles
MA Enrolled
Exchange Subsidized
ExchangeEnrolled
Compare to National and Regional Benchmarks
Medicare FFS Geo. Variation: http://go.cms.gov/1D8j7LE CDC Behavioral Risk Factor Surveillance: http://1.usa.gov/1PzcisT Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxk
Demand and Supply
Chronic Prevalence &Physician Supply
Match Practice Patterns to the right Risk Arrangements – Pay for Value Readiness
Manage Clinical Care and Costs – Remove No Value Care
Unexpected Transparency:Underserved Populations, Unwarranted Variation and Unnecessary Spend
At the core of Risk-Readiness SM is
Unwarranted Variation:
RowdMap applies the Dartmouth Atlas for Unwarranted Variation methodologies to data on Medicare Parts B & D. This research has been repeatedly validated over the last 30 years and we now have a national data set to apply the methodologies at a large scale.
The estimated 30% of medical expense that goes to unnecessary care. This unnecessary spend drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation.
Every provider has a unique practice pattern that informs Risk-Readiness SM
Pay for Value Readiness
Los Angeles, CA
Compare to National or Regional Benchmarks
Pay for Value ReadinessProvider Profiles
Identify highly efficient, Risk-Ready practices and physicians to profitably grow into. Improve profitability of lower performing practices with large panel sizes through modified arrangements
or performance improvement plans.
Medicare FFS Part B: http://go.cms.gov/OCmyoy Medicare FFS Part D: http://bit.ly/1mGyBxkReferrals: http://1.usa.gov/1FzoEOV
Identify high and low performing hospitals and post-acute facilities— are there post acute facilities that hospitals with poor chronic
readmits are routing members to?
Pay for Value Readiness
EOL Hosp Days: Which hospitals fewer end-of-life days than their peers?
Chronic Admits: Which hospitals see their most chronic population repeatedly/ with the most frequency?
Cardiac Imaging: Which hospitals are more likely to over-utilize cardiac imaging compared to their peers?
Dartmouth Atlas: http://bit.ly/1GXvlJpCMS Hospital Compare: https://goo.gl/p8MtoICMS Hospital Readmissions: http://goo.gl/02KnQdCMS Nursing Home Compare: https://goo.gl/3DpT8m
Pay for Value Readiness
Great profile for aggressive risk
Tread carefully for some risk
Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.
Chronic Prevalence &Physician Supply
Match Practice Patterns to the right Risk Arrangements – Pay for Value Readiness
Manage Clinical Care and Costs – Remove No Value Care
Unexpected Transparency:Underserved Populations, Unwarranted Variation and Unnecessary Spend
Remove no-value CareManage Unnecessary Spend
Risk-Readiness℠ looks at a different category of spending
Shift focus from clinical edits, audits, and recovery efforts to identifying care that is clinically appropriate, but unnecessary. Historical efforts have shown returns, but they only look at a fraction of total spending. Unnecessary care can account for up to 30% of total spending and provides significantly larger opportunities for cost containment and quality improvement.
Clinically Appropriate, but Unnecessary Care
(30% of spend)
Claims Spend for a Health Plan
Necessary Utilization(70%)
“It’s generally agreed that about 30 percent of what we spend on health care is unnecessary. If we
eliminate the unneeded care, there are more than enough resources in
our system to cover everybody.”
- Dr. Elliott Fisher,Dartmouth Institute for Health Policy
Remove no-value CareManage Unnecessary Spend
RowdMap tackles the 30% of the U.S. health care spend that goes to clinically appropriate, but unnecessary care
Over $9B in Orange County, CA
How much unnecessary spend is in your market?
Over $66B in Florida
$850 Billion Unnecessary Spend* in 2014
Least Unnecessary Spend
Most Unnecessary Spend
RowdMap tackles the 30% of U.S. health care spend that goes to clinically appropriate, but unnecessary care. RowdMap’s models identify the cost-savings opportunities in a geography based on the collective intensity of care delivered by doctors in that area.
* Unnecessary Spend = (Dartmouth Avg cost) * (Population) * (RowdMap Network Opportunity Index)
Remove no-value CareManage Unnecessary Spend
Unnecessary Spend in Florida
In Broward Co. alone, there is over $7.6B in unnecessary spend.
Let’s look at which hospitals, groups and physicians account for this and for what conditions
Physician Marketshare by Major Clinical Categories
Remove no-value CareManage Unnecessary Spend
Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography.
Hospital Marketshare by Major Clinical Categories
Provider Group Marketshare by Major Clinical Categories
Unnecessary Spend in BrowardBy condition across hospitals, groups and physicians
This Physician.Let’s start hereThis GroupThis Hospital
Circulatory
Muscular-skeletal
Respiratory
Remove no-value CareManage Unnecessary Spend
All contents are proprietary to RowdMap, Inc. and are being provided on a confidential basis.Any use, reproduction or distribution of this information, in whole or in part, or the disclosure of any of its contents
without the prior written consent of the Company, is prohibited.
Physicians Driving Unnecessary Care in Broward
Musculoskeletal care is major contributor to unnecessary spend in Broward. Let’s take a physician who is not an outlier but in the middle of the pack such as Dr. Spend*. Let’s walk through what his clinically acceptable, but medically unnecessary, practice pattern creates
in unnecessary spend.
Remove no-value CareManage Unnecessary Spend
Least Unnecessary Spend Most
Unnecessary Spend
Option 2: Reinforce highest-performing referral
and care pathways. Increase the number of patient interactions
with green dot doctors.
Option 1: Change provider behavior. Requires lots of provider education. Requires
payer to make up a significant portion of a provider’s revenue. Increase the number of
green dot doctors.
Zoom to zip
Remove no-value CareManage Unnecessary Spend
Referral Patterns and Physician Value Chains
Identify high performing providers and downstream referral patterns. Encourage referrals to
high-performing specialists.
Remove no-value CareManage Unnecessary Spend
If had same ratio as :• His decompression rate would drop from
6.01 to 0.436 per patient.• Which translates to 2,608 fewer
decompressions per year.• At an average cost of $332 per
decompression, this represents potential savings of over $850K
If decompression to fusion rate were average for orthopedic surgeons:
• He would have 1629 fewer decompressions for a potential savings of $540K.
*Actual physician names have been changed.
For every 10 back fusions, does 103 decompressions
For every 10 back fusions, does 2 decompressions.
Dr. Save*
Dr. Spend’s
Dr. Spend*
Dr. Save*
That’s one physician, with one procedure, in one clinical condition. This savings would not be picked up in unit cost or utilization analysis,
but cumulatively dwarfs fraud, waste and abuse outliers. Intense practice patterns like this power FFS arrangements
but success in Pay for Value comes from identifying Risk-Ready providers.
Dr. Spend*
Benchmark cost structures, benefit designs, value of providers and networks, even over/under coding and which types of risk arrangements will succeed
+ + =
Profit Opportunity Network Opportunity Price Sensitivity
Surprise:Report Cards for Health Plans
Start with Data for Business Context then add Tech.
The ACA at your finger tipsFor Payers & Providers