Risk-Ready Doctors: Network as Strategic Advantage

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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. From JV to Varsity: Using Government Benchmarks to Find Risk-Ready Providers for Your Team

Transcript of Risk-Ready Doctors: Network as Strategic Advantage

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From JV to Varsity: Using Government Benchmarks to Find Risk-Ready Providers for Your Team

QUESTION

2

Why should you pay attention for the next few minutes?

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without the prior written consent of the Company, is prohibited.

AGENDA

3

The Plan

What’s Risk-Readiness?

What’s Out There?

What to Do With It?

Govt Benchmarks in Action

About RowdMap

Q&AAll 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.

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’S RISK-READINESS?

Your world is changing…

Adequacy is just the tip of the ice berg

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How do we navigate the changing business environment ahead?

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.

Most of your payments go to FFSwith maybe some going to P4P

bonus

Payments will be much more diverse including FFS, P4P bonus, bundled payments,

shared savings, and global payments.

Payments Today Future Payment Mix

WHAT’S RISK-READINESS?

How do you turn network into a strategic advantage in this context?

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WHAT’S RISK-READINESS?

Risk-Readiness = Provider

PatternsYour

Geography

Risk-Readiness describes matchingcollective practice patterns and the

characteristics of the geographies they serve withpay-for-value programs.

+

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Every doctor practices medicine differently.

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without the prior written consent of the Company, is prohibited.

Some doctors prefer starting with lower intensity approaches…

…while others might jump right to surgery or narcotics.

The collective nuances of how each doctor practices can be aggregated into a unique practice pattern fingerprint.

WHAT’S RISK-READINESS?

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Treatment Patterns highlight differences in pace and intensity of back pain treatment

Each doc has a unique practice pattern. Some docs tend go more quickly to higher intensity options

Figure out your providers then match the revenue models

WHAT’S RISK-READINESS?

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Individual provider’s performance compared to geographic benchmarks

Build Relationships Put on Notice

Some Doctors tend go more quickly To higher intensity options

WHAT’S RISK-READINESS?

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Identify & cultivate providers for riskThis doc is making money for whoever owns the riskThis type of doc is disproportionately important to your network/group

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

WHAT’S RISK-READINESS?

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Great profile for aggressive risk

Tread carefully for some risk

Choose the right arrangement / mixBased on Your Market and Your Provider risk readiness benchmarks (practice pattern intensity)

WHAT’S RISK-READINESS?

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WHAT’S OUT THERE?

There’s a lot of data and talk out there

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WHAT’S OUT THERE?

Let’s cut through

the buzz

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Government performance

data

Government provider etc.

data

Government socio-demo

data

Consumerweb / social

data

Analysis-based deriveddata

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without the prior written consent of the Company, is prohibited.

Sentiment as a Key Driver (psychographic) - measured by Index scores for: - Domains (chronic, wellness, quality of care, customer satisfaction, customer service);- Brands (WellPoint, BCBS, your brand)[Managed via Buoy Platform]

Market Growth; Census; Healthy Food; County Health Rankings & Indicators; Behavioral Health Factors; etc.*

Dartmouth Atlas; STAR; Hospital Compare; Actual, Expected & Predicted Readmissions; Part B & D, etc.*

STAR; Price, Bid, Rebate;Hospitals, Nursing Homes; Market, etc.*

* Dozens of Primary Data Sets, updated at various frequencies

WHAT’S OUT THERE?

When we say a lot…we mean a lot.

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And it’s powerful, disruptive, game changing

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without the prior written consent of the Company, is prohibited.

David Wennberg,RowdMap Advisory Board

Government Data Outperforms Risk Adjustment!

WHAT’S OUT THERE?

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.

OPEN DATAAffordable Care Act data to determine Risk-Readiness of Providers / Networks

WHAT’S OUT THERE?

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a world where you had access to…

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without the prior written consent of the Company, is prohibited.

WHAT’S OUT THERE?

Referral patterns for your hospitals

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a world where you had access to…

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without the prior written consent of the Company, is prohibited.

WHAT’S OUT THERE?

Referral patterns for your hospitals

Well, that world is here, today.

• Even though the AMA was skeptical about these data releases for 30 years, the day has finally come.

• You have access to all of these data through government benchmarks.

• CMS understands network data like these are necessary for a competitive, direct-to-consumer health care market.

• No IT, no integration, no data warehouses—it’s here today.

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Get to know risk data for your network biz

Rank your markets and docs by Risk-Readiness

Match your docs with the right arrangements

Build your business around your network

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WHAT TO DO WITH IT?

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WHAT TO DO WITH IT?

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without the prior written consent of the Company, is prohibited.

Most data projects…

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WHAT TO DO WITH IT?

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without the prior written consent of the Company, is prohibited.

Most data projects…

All the pieces are there, but it’s still hard.

• Data project are time-consuming and complex

• Almost always questions about where the data is from

• Depending upon who generated it, data is subject to mistrust between stakeholders

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FFS Motto:“Amortize Investment”

WHAT TO DO WITH IT?

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WHAT TO DO WITH IT?

ACA Motto:“Transparency is the new black”

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Client / Your Data

Gov Data

Client / Your Data

Gov Data

Client / Your Data

Gov Data

Client / Your Data

Gov Data

Client / Your Data

Gov Data

Client / Your Data

Gov Data

Benchmarks and your data:a great match

WHAT TO DO WITH IT?

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This is a better approachNew government data outperforms claims data

Patient records & claims

Practice profiles

Geographic profiles

Market / population profiles >

David Wennberg, MDRowdMap Advisory Board

WHAT TO DO WITH IT?

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This is a shiftHow is variation informing your business model?

Focus here

Cite 20% of patients / 80% cost rule

1990s Today & tomorrow

Say “risk strat” a lot

Use big IT systems Wear Hammer pants

Focus on all the pieces including the deep drivers using patterns and profiles

Use decades or research and brand spanking new data

WHAT TO DO WITH IT?

If Dr. Berlin had same ratio as Dr. Milan:

• 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 Dr. Berlin's decompression to fusion rate were average for orthopedic surgeons:

• He would have 1629 fewer decompressions for a potential savings of $540K.

For every 10 back fusions Dr. Berlin* does 103 decompressions

For every 10 back fusions Dr. Milan* does 2 decompressions.

WHAT TO DO WITH IT?

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If Dr. Berlin had same ratio as Dr. Milan:

• 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 Dr. Berlin's decompression to fusion rate were average for orthopedic surgeons:

• He would have 1629 fewer decompressions for a potential savings of $540K.

For every 10 back fusions Dr. Berlin* does 103 decompressions

For every 10 back fusions Dr. Milan* does 2 decompressions.

WHAT TO DO WITH IT?

Magnitudes of order larger savings than traditional utilization, fraud/waste/abuse or compliance/gap closure.

For example, 1 doc in 1 county on 1 DRG funnel = $850k unwarranted / unexpected spend.

This will not show up in traditional utilization review or actuarial analysis.

If only 5% of your book is at risk, you don’t care; but when you move to pay-for-value, this will sink your battleship.

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Here’s why these benchmarks are so powerful

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GOVT BENCHMARKS IN ACTION

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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

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KEY QUESTIONS:

Where is the demand?

Where is the supply?

Which docs match which risk arrangements?

How do I structure my business around this?

(growth alignment, benefit design, STAR/QRS)

GOVT BENCHMARKS IN ACTION

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County Health Factors Average Risk Scores

GOVT BENCHMARKS IN ACTION

Population Demand & Provider Supply

Where is health risk underrepresented or under-coded?

Which areas have lower risk scores than their behavioral profile / cost drivers.

In other words, where does the population sees providers less and therefore has a lower risk profile based on the geography’s ‘supply’.

Health Opportunity Index

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Cost Projection & Network Demand

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

Which counties are high/low performers? What are the characteristics of my counties?

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Diabetes Prevalence –LA County

PCP Density –LA County

Income

Obesity

Depression

Population Demand & Provider Supply

GOVT BENCHMARKS IN ACTION

Proximity to provider is more important for this geography. Is my network aligned to not only meet adequacy

but to reflect my member demographic?

34

Network Opportunity Index (NOI)

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

Where are providers delivering the most efficient and appropriate care?

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Which providers match which arrangements

Good candidates for full cap and aggressive risk

arrangements

Tread carefully and ramp up with upside here

GOVT BENCHMARKS IN ACTION

Provider Risk-ReadinessLos Angeles County, CA

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What’s driving a specific provider’s performance in comparison to peers?

GOVT BENCHMARKS IN ACTION

Los Angeles County, CA

Provider Benchmarks

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These are good Candidates

To focus on Growth using the Growth

PlayBook

Los Angeles County, CAIndividual Physicians

These are good Candidates to

focus on Efficiency using

the Network PlayBook

GOVT BENCHMARKS IN ACTION

Physician Risk-Readiness

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What’s driving a specific provider’s performance in comparison to peers?

Los Angeles County, CAPhysician Benchmarks

GOVT BENCHMARKS IN ACTION

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Market Share & Hospital Benchmarks

Hospital Profiles

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

Cedars Sinai Medical Center

Los Angeles County, CA

Where are providers delivering the most efficient and appropriate care?

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How do my hospitals perform against national benchmarks?

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?

GOVT BENCHMARKS IN ACTION

Hospital Profiles and Risk Drivers

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How do my post acute centers perform against national benchmarks? How are my hospitals routing, especially those

with poor chronic readmits & post discharge rates?

GOVT BENCHMARKS IN ACTION

Post Acute Center Benchmarks

Spending 1-30 Days Post Discharge

Olympia Med Center

Readmissions

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What are the patterns of care and preferred pathways?

GOVT BENCHMARKS IN ACTION

Hospital Risk Drivers

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Population Demand & Risk Alignment

GOVT BENCHMARKS IN ACTION

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Price Sensitivity

What price points do I need to hit to be able to grow quickly?Where do I run the risk of commoditization?

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Market Portfolio Position

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

What price points do I need to hit to be able to grow quickly?Where do I run the risk of commoditization?

Portfolio Positioning & Risk Alignment

45

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

Benefit Configuration & Risk Alignment

What are the winning patterns that draw growth?What trade offs should I make given my network?

Avg

Pay Later

Pay Now

Typical Markets have at least two ‘Winning Patterns:’

Pay Now & Pay Later

HealthNet

HealthNet

Aetna

Los Angeles

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Does my Network meet adequacy standards?It is optimized for Risk-Readiness?

Adequacy Optimized for Risk-Readiness

GOVT BENCHMARKS IN ACTION

Adequacy & Referrals

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How aggressively are my PCPs referring patients to specialists? Do the specialists focus on pain management or surgery?

Are the specialists in or out of my network? How are the specialists performing?

Key Marker: Referral to Pain Management vs. MRI

Primary Care Physicians (% of Back-related Referrals)

InNetwork

Out of Network

InNetwork

Out of Network

InNetwork

Out of Network

InNetwork

Out of Network

InNetwork

Out of Network

InNetwork

Out of Network

This PCP sends lots of patients to In-Network surgeons who perform poorly

GOVT BENCHMARKS IN ACTION

Referrals and Risk-Ready Networks

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Los Angeles, County

What is the actual, not necessarily the contracted,

patient flows between providers (paths of least resistance) in my market?

Inbound Referrals

Outbound Referrals Informal Network

1Informal Network

2

Informal Network 3

Informal Network 4

GOVT BENCHMARKS IN ACTION

Natural Networks and Risk-Readiness

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PCPs

What is the actual, not necessarily the contracted,

patient flows between providers (paths of least resistance) in my market?

Radiologist

Ortho

GOVT BENCHMARKS IN ACTION

Care Paths and Risk-Ready Networks

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Growth and Risk-Readiness

GOVT BENCHMARKS IN ACTION

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without the prior written consent of the Company, is prohibited.

Which counties will likely generate profit in a P&L given my network’s characteristics?

California

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Top Rep / Broker aligned with Most Risk-Ready Provider

Bar = Provider and Membership; Color = Producer

No alignment between sales and network (looks like a pack of skittles blew up)

Alignment between sales and network (looks like Legos making solid color bars)

Align your best reps with your best providers to build meaningful relationships and grow into the right providers. This is more what it should look like. The best producer is concentrating his efforts on

the most Risk-Ready providers.

GOVT BENCHMARKS IN ACTION

Growth and Network Risk-Readiness

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Provider A Provider B

Throttle efforts between sales and network on select providersbased on Risk-Readiness to maximize profitability.

GOVT BENCHMARKS IN ACTION

Growth and Network Profitability

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Success Using this Data• 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…

ABOUT ROWDMAP

54

Founders & Team – Multiple SuccessfulAnalytic Companies

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without the prior written consent of the Company, is prohibited.

Melanie Rosenthal – CEOCo-Founder & CEO @ Sprigley [acquired by Eliza Corporation, 2008]; VP of Product Ops @ Eliza [Majority EquityInvestment Parthenon Capital, 2011]; Health Dialog, Yale, Human Genome Project, Tufte, Solstice Capital

Burak Sezen – CIOCo-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 – CSOCo-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) Speaker/Guest Lecturer/Guest @ Harvard, Johns Hopkins, MIT , SXSW, HDI, RWJ, AF4Q, NPR (with US CTO and HHS CTO)

Kimberly Spalding, CPA – CFOCo-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

Industry-Leading Advisory Board

ABOUT ROWDMAP

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Featured Nationally US CTO on RowdMap: “Visionary

Genius”

ABOUT ROWDMAP

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ABOUT ROWDMAP

Want to see insights RowdMap has on your network, your geography, and your competitors?

We can schedule a time at the conference to walk through the benchmark data we already have about your plan and geography (no IT involved!)

QUESTION

57

Any Questions?

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