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.
Capturing Your Hidden Value: Using Newly Released Government Benchmark Data to Select Value Programs and Negotiate Risk Arrangements
Jan 22, 2018
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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.
2All 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.
What RowdMap Does
Risk-Readiness SM and You
Rothman Instituteas Best Practice
3All 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.
What RowdMap Does
Risk-Readiness SM and You
Rothman Instituteas Best Practice
4All 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.
WHAT WE DOIt’s Time for Risk
CMS: 50% of FFS will be gone by 2018
CMS Means Business!
These are just the first pieces to move and transforming
payment across the system!
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.
5All 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.
Featured Nationally US CTO on RowdMap: “Visionary
Genius”
WHO WE AREFounders & Team
6All 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.
Melanie Rosenthal – Chief Executive OfficerCo-Founder & CEO @ Sprigley [acquired by Eliza Corporation, 2008]; VP of Product Ops @ Eliza [Majority Equity Investment Parthenon Capital, 2011]; Health Dialog, Yale, Human Genome Project, Tufte, Solstice Capital
Burak Sezen – Chief Information OfficerCo-Founder & CTO @ Sprigley [acquired by Eliza Corporation, 2008]; Platform Architect @ Eliza [Majority EquityInvestment Parthenon Capital, 2011], Health Dialog, Pricewaterhouse Coopers; Ernst & Young; Standards Committees
Joshua Rosenthal, PhD – Chief Scientific OfficerCo-Founder & CSO @ Sprigley [acquired by Eliza Corporation, 2008]; VP of Product Ops @ Eliza [Majority Equity Investment Parthenon Capital, 2011], Fulbright, Sorbonne (Applied Institute for Advanced Studies),HHS/CMS/ONC/NCHVS Public Adviser (Technology & Innovation, Market & Policy, Data Access) and HCTTFSpeaker/Guest Lecturer/Guest @ Harvard, Johns Hopkins, MIT , SXSW, HDI, RWJ, AF4Q, NPR (with US CTO and HHS CTO)
Henriette Coetzer, MD – Chief Clinical Risk OfficerClinical Transformation, NHS (National Health Service, United Kingdom); Global Medical Director, Towers Watson; Senior MedicalDirector and Clinical Analytics, BUPA and Health Dialog; Product Development, Healthways; Practicing Physician; Patent Holder
Kimberly Spalding, CPA – Chief Financial OfficerCo-Founder Tech Republic [acquired by CNET, 2001]; Co-founder & CFO Narrowcast [acquired by QuinStreet, 2011]; Ernst &Young’s Entrepreneurial Services
Bryant Hutson & Ashley Distler – Senior Client StrategistsCornell, Xavier; Cincinnati Children’s Hospital, Optimity Advisors, Presence Health; Skydiver, Travel Connoisseur
WHO WE AREFounders & Team
Industry Leading Advisory Board
WHO WE AREWhere It’s Worked
7All 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.
RowdMap Success Stories• Increased a plan’s membership through smart growth by 40,000
in 12 months; and another plan’s by 40% in the same time
• Reduced membership attrition for a SNP plan in a competitive metro by 20%
• Launched high-end concierge plan that broke member price sensitivity and generated significant profit, doubling original membership goal
• Launched a purpose-built plan for a curated provider network
• Increased a plan’s Star scores by a full point through provider-centric growth
• Designed product strategy and corresponding benefits for a major metro areathat lead to plan’s first profitable product portfolio in three years
• Aligned a plan’s sales and network team strategy around providers
• Tripled a plan’s original goal of contracting with targeted providers (and in some cases, out of exclusivity arrangements)
• Shifted a plan’s majority of membership from PPO to HMO, doubling original goal
• Moved a plan’s membership in target providers from 2% to 30% in target providers in 12 months
• Articulated clear data-driven MA strategy for board-level presentations that resulted in additional investments
• Developed comprehensive strategy for government affairs that created an advantageous environment for plan and members
Where we’ve done it…
8All 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.
What You Get with RowdMapTechnology and Professional Service
EnterprisePlatformLicenseLicense covers entire enterprise across all functional units and all (reasonable) users and usage
RowdMap UOnline Learning CenterOne of a kind web-based resource with tips, tricks, tutorials and functionally-oriented resources to help users understand, and interpret the information
BenchmarksDrill Downs and ProfilesPayer Profiles, Provider Profiles, Market and Geographic Profiles Including Social Determinants and Health Behaviors
On-site Analytic WorkshopsRowdMap prepares an analysis across functional areas and presents data, interpretation and recommendations
Auto-Generated ReportingSelf-serve dashboards and reporting with tagging and sharing that export as PDF or PPT
EnrichmentClient DataRowdMap accepts and integrates your data and incorporates it within the RowdMap platform
Risk Readiness Your Provider Profiles,Available Risk Arrangements,Risk Arrangement Matching,Payer/Provider Risk Profiles
Year in the Life Custom Analyses & SupportProvider Performance Profiles and Risk-Readiness AnalysisNew Payment Model Opportunity AnalysisReimbursement Opportunity and Payer Profile AnalysisPolicy and Regulatory Analysis
9All 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.
As payment models change, the system is looking intently to find better ways of managing risk. (Who is Risk-Ready SM ?)
The new world of risk
WHAT WE DORisk-Readiness SM
And… is your profile coherent, cohesive and consistent?In a world intently focused on managing risk, variation is the enemy. To outsiders (payers), variation is hard to predict and hard to interpret To insiders (within your practice), variation is disruptive and difficult to implement standards against.
We are going to show you what your practice looks like from a risk management perspective (your Risk-Readiness SM profile).
Do you look like a good risk partner?The right: market position, mix of procedures & drugs, referral partners, practice profile and docs
10All 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.
Plan from prevalence & physician supplyPopulation Report CardPopulation Health ReportPopulation Supply and Demand ReportPopulation Over-coding / Under-coding Report
Match your practice patterns to the right arrangementsRisk-Readiness SM ProfileRisk-Readiness SM LandscapeRisk-Readiness SM Value Chain Referral and Leakage AnalysisRisk-Readiness SM Arrangement Match-MakerRisk-Readiness SM Medical Economics Report
Negotiate using government benchmarksPayer Report CardPayer Profit Driver ReportPayer Product Impact ReportPayer - Provider Negotiation ReportPayer - Provider Network Adequacy and Optimization Report
11All 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.
What RowdMap Does
Risk-Readiness SM and You
Rothman Instituteas Best Practice
12All 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.
Risk-Readiness℠ looks at a different category of spending
ACOs, MSSP, Capitation, VBPO: Goal Is to Get Ridof the 30 Cents of Every Dollar of No-Value Care
Clinically Appropriate, but Unnecessary Care
(30% of spend)
Claims Spend for a Health Plan / Government Program
Necessary Utilization(70%)
“Bigger than higher prices, administrative expenses, and fraud, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.”
In just a single year, up to 42% of patients receive “No Value” Care.
Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School.
“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
13All 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.
At the core of Risk-Readiness SM is
Unwarranted Variation: Every provider has a unique practice pattern that informs Risk-Readiness SM
Low and Now Value Care Defined by Decades of Publicly Available Research
Apply the Dartmouth Atlas for Unwarranted Variation methodologies to the newly released CMS data. 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.
Grey area outside of obvious fraud but based on choice of two options for care that yield same outcomes, but one at marked
higher costs. Definitions across PCP care, specialties.
Provider with High Intensity Practice Pattern
Maximizing Fee for Service
Provider with Low IntensityPractice Pattern Maximizing Pay for Value
14All 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.
Magnitude of Problem Means Darwinian Approach30% of the U.S. health care spend goes to no value care and unnecessary spending driven by FFS Incentives
Over $66B in Florida
$850 Billion Unnecessary Spend* in 2014
30% of U.S. health care spend that goes to clinically appropriate, but unnecessary care. Newly released data and historic models can 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) * (Network Opportunity Index)
Concern Is One Model Won’t Work for All;New Models Win that Mitigate this 30 Cents
RAND/AMA study confirms providers face challenges, especially on data, and may not be able to achieve success.
CMS A/B testing payers and providers across a wide variety of programs and ratcheting economics to find winners.
Over $9B in Orange County, CA
15All 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.
Medicare DocGraph Referral file (Patient flows between PCPS, specialists, hospitals and post acute centers)
Dartmouth Atlas of Health Care & Choosing Wisely(Decades of research and data on unwarranted variation by condition and geography to keep things apples-to-apples for comparisons)
CMS FFS Data Sets, CDC Data Sets (MEDPAR, Part B, Part D, BRFSS)(Individual providers, groups, hospitals and post acute centers)
Provider Pattern Intensity Profiles and Risk Readiness for every provider, hospital, post acute center in the US. All preloaded with no IT.
New Government Benchmark DataParticularly powerful when pulled together
Affordable Care Act data to determine Risk-Readiness SM of Providers / Networks
CMS Historic Releases of Largest Provider Data;Virtually Every Provider, Group, Hospital, Etc.
Here’s why these benchmarks are so powerful
16All 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.
Government benchmark data serves as the common languagenecessary to build relationships with providers to improve the member experience and profitability
The benchmarks are available today with no IT involvement
The data already have a level of analysis on top, so you can see if a provider is over/under benchmarks
It’s from CMS; it’s a standard; it’s already used to day to drive reimbursement
CMS Benchmarks Work across all Geographies, Populations, P&Ls (Care, Caid, Commercial, etc.)
17All 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.
Hospital Marketshareby Major Clinical Categories
Provider Group Marketshareby Major Clinical Categories
Physician Marketshare by Major Clinical Categories
MSSP Candidate
Circulatory
Respiratory
Unnecessary Spend in MiamiBy condition across hospitals, groups and physicians
Know Your Market and How Much / Little No-Value Care You Create in It
Large purple boxes are most difficult targets. Large light boxes are great candidates. Small purple have work to do. Small light
should focus on growth.
Next Gen ACO Candidate
18All 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.
Know Your Market and How Much / Little No-Value Care You Create in It
Diabetes Prevalence PCP Density
Income
Obesity
Depression
Demand vs. Supply
Sick and underserved
Westchester, NY
RowdMap’s Population Health Report helps you allocate care management resources around condition-specific population needs by zip.
For example, reassess expansion and PCPS contracting strategies by zip code or locate retail clinics, RVs and health fairs based on chronic needs.
Population Health Report
19All 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.
Know Exactly What Drives Success in Each Type of ACO or Value Based Arrangement in Your Market
Largest Counties in CA
Regional Benchmarks
Risk Scores
Total Cost
PMPM
Reimbursement
Overall Star
Chronic Star
Health Rank
Network Opportunity
Profit Opportunity
MA
Profit Opportunity
Exchange
MedicareEligibles /
MA Enrolled
ExchangeSubsidy Eligibles /Exchange Enrolled
MedicaidBeneficiary Eligibles /
Beneficiaries
Population Report Card
RowdMap’s Population Health Report helps you calibrate Expectations for profitability by incorporating population
health and provider performance into strategy.
For example, some geographies lend themselves to volume and profitability around specific products and lines of service.
20All 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.
Know Your Practice Pattern, Its Drivers, and How You Compare to Your Competition
Orange County, CA
Regional Benchmarks
Identify and highlight highly efficient, Risk-Ready practices. For example, focus resources and growth opportunities in these
practices and share best practices with other physicians.
Group Risk-Readiness SM Report
21All 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.
Know Your Practice Pattern, Its Drivers, and How You Compare to Your Competition
PCPs
Identify low cost, highly efficient physicians and make them your stars. For example, feature them in risk arrangements.
Physician Risk-Readiness SM Report
Regional Benchmarks
Jefferson Co, KY
22All 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.
Know Your Practice Pattern, Its Drivers, and How You Compare to Your Competition
California
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?
Regional Benchmarks
Highlight and focus on relationships with low cost and efficiency in end of life and chronic care. For example, target for referral management or use them as levers for risk contracting with payers and government programs.
Hospital Risk-Readiness SM Report
23All 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.
Know Your Practice Pattern, Its Drivers, and How You Compare to Your Competition
Identify high and low performing post-acute facilities. Consider planning post-discharge interventions and protocols with
the highest performing facilities.
Post Acute Center Risk-Readiness SM ReportWestchester County, NY
24All 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.
Decreased Cost
Average
Increased Cost
Less
Eff
icie
nt
1
2
3
4
5
Mo
re E
ffic
ien
t
Miami Dade, Florida
Risk-Readiness SM
Benchmark
Impact on Spend
Know Exactly How Much Value You Create for Whoever Owns the Risk in Any Arrangement
$ PMPY per Specialty & Efficiency Score
Providers ‘hidden value’ can be quantified into dollars from how much no-value care they mitigate. These dollars are translated into different ACO, MSSP, Capitation arrangements differently. Make sure you pick the right program / arrangement in order to maximize your value and
get credit for your work.
25All 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.
Know Exactly How Much Value You Create for Whoever Owns the Risk in Any Arrangement
Primary Care Docs
SpecialistPost Acute
Facility
Thickness of lines indicates the number of referrals. Note: Some markets are
oversupplied. This market is controlled by one provider.
Less efficient
More efficient
Identify PCPs that refer to higher intensity specialists. Consider new contracting arrangements and provider education to
improve overall care efficiency.
Risk-Readiness SM Value Chain Referral and Leakage Report
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.26
Negotiate from Health Plan’s Expected Pro Forma, Strengths, Weakness and Provider Contribution
Payer Profiles and Report Cards
If opting for a virtual ACO or other capitated arrangement with a payer partner, determine which payers have acute needs and where and how you help them. For a payer with low reimbursement, poor population
health scores, poor overall clinical metrics and a small population, negotiate less from your medical performance and
more from your coding and panel size.
Blue = Volume
Every Payer in your market
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.27
Unless a utilization review or actuarial analysis can connect points on the no/low-value care path and address the entire bundles they miss
the largest pocket of value, even when case mix adjusted
This doctor has lower utilization and unit costs
But this doctor is making money for whoever owns the risk
Providers Who Mitigate No/Low-Value CareOften Do Not Get Credit
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.28
Unless a utilization review or actuarial analysis can connect points on the no/low-value care path and address the entire bundles they miss
the largest pocket of value, even when case mix adjusted
Providers Who Mitigate No/Low-Value CareOften Do Not Get Credit
This doc is making money for whoever owns the risk across value based arrangements
She might not be the highest producing and may cost more…
…but she’s disproportionately reducing unwarranted costs and unnecessary negative
impact and patient experience
29All 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.
New Public Data Shows Risk-Readiness SM and Drivers for Groups, Individual Physicians
Practice patterns for unnecessary spending and no-value care benchmarked nationally and regionally inform government
programs and payer-based risk arrangements
Great profile for aggressive risk
Tread carefully onpath to risk
Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography
30All 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.
CMS: 50% of FFS will be gone by 2018
What if you knew which providers would
drive your success?
What if you knew which providers would sink you?
Here’s who will win and who will lose
31All 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.
What RowdMap Does
Risk-Readiness SM and You
Rothman Instituteas Best Practice
Mike West, CEO
32All 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.
Philadelphia, PA
Orthopedic Surgeons OnlyGroup Risk-Readiness SM Report
Rothman InstituteBest Practice at Risk-Readiness SM
Rothman Institute
The most Risk-Ready orthopedic group in Philadelphia. Practicing care in a way designed to maximize value based risk arrangements.
Large patient panel and the best performing, and Best Practice at mitigating unnecessary spending from no / low value care.
Performing above national and regional benchmarks in every category.
33All 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.
Philadelphia, PA
Orthopedic Surgeons OnlyGroup Risk-Readiness SM Report
Rothman InstituteBest Practice at Risk-Readiness SM
Questions for Mike West, CEO, Rothman Institute
1 – What have you done to achieve this Risk-Readiness SM ?
2 – What does this data allow you to do and what are your plans?
Related Documents
