IT Solutions for Fee for Value Reimbursment and Population Health Management
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IT Solutions for Fee for Value Reimbursment and Population Health Management

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This presentation highlights some key considerations when building or integrating IT solutions for the emergent payment models evolving in Health Care. Population risk stratification, identifying ...

This presentation highlights some key considerations when building or integrating IT solutions for the emergent payment models evolving in Health Care. Population risk stratification, identifying patients to target for high success rate interventions, and tracking physicians adherence to evidence based medicine using key performance indicators are covered at a high level.

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  • Thank you for attending this sessionTHE TOPIC this session is TECHNOLOGY CONSIDERATIONS FOR VALUE-BASED PAYMENTSMy name is John Squeo, TITLEVANGUARD HEALTH SYSTEMSInvestor Owned Health Delivery System28 HospitalsDOCTORS in 1000 Care settings across the United StatesInvestor-Owned Healthcare Service ProviderHeadquartered in Nashville VHS owns and operates acute care hospitals and outpatient facilities located in urban and suburban markets in the US28 Acute and Specialty Hospitals 40,000 Employees2012 Revenue $5,949 B2012 Adjusted Discharges 518,0002012 Adjusted EBITDA $575.7 MCurrently undergoing a major transformation in the way we are being compensated by the Payers such asMEDICAREMEDICAIDANDCommercial CarriersTHIS IS A BROAD TOPIC WITH A LOT OF INFORMATION SO PLEASE HOLD YOU QUESTIONS TO THE END UNTIL THE Q & A
  • According to the 2011 Annual Survey American College of Healthcare Executives – THE BIGGEST ISSUES FACING HOSPITAL CEOs
  • According to the 2011 Annual Survey American College of Healthcare Executives – THE BIGGEST ISSUES FACING HOSPITAL CEOs
  • Last week, Rep. John Lewis (D-Ga.) proposed the DSH Reduction Relief Act, which would delay Medicare and Medicaid DSH payment cuts until the government's 2016 fiscal yearIL Bill Status of SB2840  98th General Assembly Senate SponsorsSen. Heather A. Steans - John G. Mulroe"pay and chase" model to a prospective pre-payment model - Contains provisions concerning eligibility and payment verifications; data sharing; and the benefits of a pre-payment, post-adjudication, and post-edit claims system
  • YESTERDAY – MARILYN TAVENNER WAS CONFIRMED AS ADMINISTRATOR FOR CMS ON A 91-7 SENATE VOTEFIRST CMS ADMINSTRATOR SINCE DR. McCLELLAN BACK IN 2006
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • Big Box Concepts FAIL when competitors enter with better LOCALIZED Access & ConvenienceCONSUMER PRICE TRANSPARENCYThese amounts can vary widely.  For example, average inpatient charges for services a hospital may provide in connection with a joint replacement range from a low of $5,300 at a hospital in Ada, Okla., to a high of $223,000 at a hospital in Monterey Park, Calif.Centers for Medicare and Medicaid Services, May 8, 2013
  • ACCESS TO A PROVIDER IS A KEY OPPORTUNITY TO REDUCE COSTSTORY - $150 OFFICE VISIT VS. $4000 ER VISIT FOR COPD PATIENT
  • ACCORDING TO THE US Agency for Healthcare Research and Quality
  • ACCORDING TO THE US Agency for Healthcare Research and Quality
  • ACCORDING TO THE US Agency for Healthcare Research and Quality
  • Dr. Ann Graybiel at MIT has performed research on the habits of RatsNerve fibers grow and strengthen creating Long-Term memory and behaviorsThe action becomes Hard Wired and mind has a tendency to use ROBUST neural linkages for instinctual or regular activitiesAnatomical Change versus Operational neural linkagesLike moving from doing things in flexible software to doing the task in a DSP or ASIC processor
  • Dr. Ann Graybiel at MIT has performed research on the habits of RatsNerve fibers grow and strengthen creating Long-Term memory and behaviorsThe action becomes Hard Wired and mind has a tendency to use ROBUST neural linkages for instinctual or regular activitiesAnatomical Change versus Operational neural linkagesLike moving from doing things in flexible software to doing the task in a DSP or ASIC processor
  • Dr. Ann Graybiel at MIT has performed research on the habits of RatsNerve fibers grow and strengthen creating Long-Term memory and behaviorsThe action becomes Hard Wired and mind has a tendency to use ROBUST neural linkages for instinctual or regular activitiesAnatomical Change versus Operational neural linkagesLike moving from doing things in flexible software to doing the task in a DSP or ASIC processor
  • Dr. Ann Graybiel at MIT has performed research on the habits of RatsNerve fibers grow and strengthen creating Long-Term memory and behaviorsThe action becomes Hard Wired and mind has a tendency to use ROBUST neural linkages for instinctual or regular activitiesAnatomical Change versus Operational neural linkagesLike moving from doing things in flexible software to doing the task in a DSP or ASIC processor
  • LEADS TO IRRATIONAL DECISIONS SUCH AS THIS PROVIDE COACHING TO PEOPLE TO HELP THEM RE-THINK THEIR OLD ASSUMPTIONSONE CLEAR OPPORTUNITY IS FOOD PORTION CONTROLREAL TIME TRIGGERS OR COACHING TO HELP THEM
  • LEADS TO IRRATIONAL DECISIONS SUCH AS THIS PROVIDE COACHING TO PEOPLE TO HELP THEM RE-THINK THEIR OLD ASSUMPTIONSONE CLEAR OPPORTUNITY IS FOOD PORTION CONTROLREAL TIME TRIGGERS OR COACHING TO HELP THEM
  • WHAT CAN TECHNOLOGY TELL US ABOUT POPULATION HEALTH?According to the National Institute of Health Care Management1% of Insured USED $90K per person in health care expenses in 20115% accounted for $41K per person50% of the insured average only $236 in health care expenses in 2011MAIN COST DRIVERS OBESITY RELATED HEART DISEASE Diabetes ArthritisOn Track in 2012 for !4,250 Transplants at average cost of $730K eachIF WE CAN IDENTIFY WHICH PEOPLE ARE HEADED TOWARDS THESE DISEASES, WE CAN INTERVENE EARLY ON AND AVOID THE HIGH EXPENSE
  • USE PROBABILISTIC MATCHING ALGORITHMONLY IF NEEDED Hadoop HIVE Hbase for MAP REDUCE JOBS
  • USE PROBABILISTIC MATCHING ALGORITHMONLY IF NEEDED Hadoop HIVE Hbase for MAP REDUCE JOBS
  • USE PROBABILISTIC MATCHING ALGORITHMONLY IF NEEDED Hadoop HIVE Hbase for MAP REDUCE JOBS
  • USE PROBABILISTIC MATCHING ALGORITHMONLY IF NEEDED Hadoop HIVE Hbase for MAP REDUCE JOBS
  • USE PROBABILISTIC MATCHING ALGORITHMONLY IF NEEDED Hadoop HIVE Hbase for MAP REDUCE JOBS
  • Story of the new Apple IIc in 1984 for $1,550, that’s $3,450 (2012 dollars) Grandma asks me what I was going to use it for? My answer, I am going to do word processing and do spreadsheets. Grandma stated – That’s useless! For that much money! Where is the TV antennae? Can get the weather? Can it show me when things go on sale? We just laughed because clearly she DID NOT GET that this was something completely new and not a TV. Funny things is, I think I use my home computer to check the weather and buy things more than anything else. She was prophetic whether, intended or not. That story proves how hard it is to innovate or idealize a 3rd order horizon. Sometime is takes a person of incredible genius or incredible naivety to state a “game changing” prospect. “They did not know it was impossible, so they did it.” Source: Mark Twain  Digital Natives 30 years old or youngerDigital Immigrants over 30Source: Marc Prensky - Digital Natives, Digital Immigrants published in 2001
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • Need for Semantical Interoperability
  • HOW DO WE DO REACH THE PATIENT TO INFLUENCEGOOD HEALTH JUDGEMENTS?DIFFERENT METHODS OF OUTREACH WEB PORTALS EMAIL TEXTING SOCIAL MEDIA CALL CENTERS IVR INTERACTIVE VOICE RESPONSE SYSTEMS HOME HEALTH CARE – CASE MANAGERSPROMOTE EXERCISE AND DIETMEDICATION COMPLIANCESMOKING CESSATION PROGRAMS
  • HOW DO WE DO REACH THE PATIENT TO INFLUENCEGOOD HEALTH JUDGEMENTS?DIFFERENT METHODS OF OUTREACH WEB PORTALS EMAIL TEXTING SOCIAL MEDIA CALL CENTERS IVR INTERACTIVE VOICE RESPONSE SYSTEMS HOME HEALTH CARE – CASE MANAGERSPROMOTE EXERCISE AND DIETMEDICATION COMPLIANCESMOKING CESSATION PROGRAMS
  • HOW DO WE DO REACH THE PATIENT TO INFLUENCEGOOD HEALTH JUDGEMENTS?DIFFERENT METHODS OF OUTREACH WEB PORTALS EMAIL TEXTING SOCIAL MEDIA CALL CENTERS IVR INTERACTIVE VOICE RESPONSE SYSTEMS HOME HEALTH CARE – CASE MANAGERSPROMOTE EXERCISE AND DIETMEDICATION COMPLIANCESMOKING CESSATION PROGRAMS
  • HOW DO WE DO REACH THE PATIENT TO INFLUENCEGOOD HEALTH JUDGEMENTS?DIFFERENT METHODS OF OUTREACH WEB PORTALS EMAIL TEXTING SOCIAL MEDIA CALL CENTERS IVR INTERACTIVE VOICE RESPONSE SYSTEMS HOME HEALTH CARE – CASE MANAGERSPROMOTE EXERCISE AND DIETMEDICATION COMPLIANCESMOKING CESSATION PROGRAMS
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • Alan Snell CMIO – St. Vincent's’ Ascension Health, IndianapolisJacci Nickell, VP Development & Operations Delivery – Good Sam Society, Sioux Falls, SD
  • STORY OF REDUCING THE WEIGHT OF A PATIENT BY AN ACHIEVABLE TARGET TO REDUCE THE PROBABILITY OF ONSET OF TYPE 2 DIABETES
  • HABITS
  • QUESTIONS?>>>>>>>>>>>>>LISTEN TO AUDIENCE………..I WANT TO THANK YOU FOR ATTENDINGI CAN BE REACHED ON LINKEDIN by searching for JOHN SQUEO

IT Solutions for Fee for Value Reimbursment and Population Health Management IT Solutions for Fee for Value Reimbursment and Population Health Management Presentation Transcript

  • John Squeo Lazer Focus Advisors Find us on LinkedIn
  • 1% of U.S. population consumes 20% of ALL HEALTH CARE DOLLARS Source: National Institute of Health Care Management 2012
  • 1% of U.S. population consumes 20% of ALL HEALTH CARE DOLLARS Source: National Institute of Health Care Management 2012 Total expenditure on healthcare: per capita per year: $7,960 Source: Organization for Economic Co-operation and Development on global health issues: Michael B. Sauter, Charles B. Stockdale, 24/7 Wall St. , 2012 - Countries that spend the most on health care, NBCNEWS.com, http://www.nbcnews.com/business/countries-spend-most-health-care-618241 Expenditure as percent of GDP: 17.4 percent
  • #3 Biggest Issue – Patient Safety & Quality 2011 Results - Biggest Issue Facing Hospital CEOs Source: American College of Healthcare Executives, Annual Poll – Top Issues Confronting Hospitals: 2012 Annual Survey American College of Healthcare Executives
  • #3 Biggest Issue – Healthcare Reform Implementation 2012 Results - Biggest Issue Facing Hospital CEOs Source: American College of Healthcare Executives, Annual Poll – Top Issues Confronting Hospitals: 2012 Annual Survey American College of Healthcare Executives
  • •Hospital Readmissions– Hospital DRGs 1% in 2013 3% by 2015 •Medicaid DSH cuts - $18.1Billion 2014 – 2020 (Pres. Obama proposed delay to 2015) •Value-Based Purchasing •70% - Core Measures: Heart Failure, Acute Myocardial Infarction (AMI), Pneumonia & Surgical Care •30% - HCAHPS score: Patient Satisfaction •Physician (SGR) Sustainable Growth Rate – 27% Reduced Reimbursements CMS & Commercial Carriers •Accountable Care – Provider Risk Acceptance & Shared Savings •Bundled payment for episodic care Global Payments Innovations – CMS & Carriers •Payers setting up Accountable Care Organizations •Hospital Systems offering health insurance on public Health Insurance Exchanges (HIX) Payer/Provider Convergence
  • HHS & ONC BEACON COMMUNITIES HIE - HEALTH INFORMATION EXCHANGES  SEMANTICAL INTEROPERABILITY  MASTER PROVIDER INDEXES  MASTER PATIENT INDEXES  CONSENT MANAGEMENT & RECONCILIATION ILLINOIS - Care Coordination Programs  CCE - Seniors and Persons with Disabilities  CCMN - Children with Complex Health Needs  MMAI - Medicare-Medicaid Alignment Initiative  ICP - Integrated Care Project and Integrated Care Expansion
  •  ACO – ACCOUNTABLE CARE ORGANIZATIONS  BUNDLED PAYMENTS FOR CARE IMPROVEMENT  PRIMARY CARE TRANSFORMATION  MEDICAID & CHIP POPULATION INITIATIVES  DUAL ELIGIBLES INITIATIVES  PAYMENT & SERVICES DELIVERY MODEL ACCELERATION  BEST PRACTICE ADOPTION INITIATIVES
  • Year 1 Attribution Year 2 Year3 Shared Savings ACO CMS or Other Payer ACO
  • Year 1 Attribution Year 2 Year3 Shared Savings ACO CMS or Other Payer ACO
  • Year 1 Attribution Year 2 Year3 Shared Savings ACO CMS or Other Payer Risk Score Profiling Chronic Disease Monitoring ACO
  • Year 1 Attribution Year 2 Year3 Shared Savings ACO CMS or Other Payer Risk Score Profiling Chronic Disease Monitoring Care Coordination Pre & Post Acute Care ACO
  • Managed Care and Value-Based Care has provided us the privilege and responsibility to Never Discharge a Patient. We can dedicate our efforts to help them grow, contribute and then age with dignity.
  • MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital
  • MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital
  • MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital CONSUMER DRIVEN HEALTH CARE Source: http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals- charge.html
  • COMPACT RADIUS OF PATIENTS/COMMUNITY DEFINED PAYER MIX HOSPITAL PATIENT CAPTURE CURRENT STATE MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital CONSUMER DRIVEN HEALTH CARE Source: http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals- charge.html
  •  SILVER TSUNAMI – Seniors Aging In Their Homes  78 Million Baby Boomers turned 65 in 2011  9 out of 10 seniors want to stay in the home they retied in Source: AARP survey  REDUCED HOSPITAL READMISSIONS  REDUCED HOSPITAL (LOS) LENGTH OF STAY + __________________________________________ MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital CONSUMER DRIVEN HEALTH CARE Source: http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals- charge.html
  •  SILVER TSUNAMI – Seniors Aging In Their Homes  78 Million Baby Boomers turned 65 in 2011  9 out of 10 seniors want to stay in the home they retied in Source: AARP survey  REDUCED HOSPITAL READMISSIONS  REDUCED HOSPITAL (LOS) LENGTH OF STAY + __________________________________________ EXPANDED RADIUS OF PATIENTS EXPANDED PAYER MIX BIG DRIVE TIME TO REACH PATIENTS MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF CARE Hospital CONSUMER DRIVEN HEALTH CARE Source: http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals- charge.html
  • Source: Southcentral Foundation, “The Trust for Health Excellence’s Better Health Initiative”
  • Source: Southcentral Foundation, “The Trust for Health Excellence’s Better Health Initiative” Influence the RIGHT PEOPLE at the RIGHT TIME at the RIGHT PLACE by the RIGHT METHOD USE PATIENT OUTREACH TO
  • Source: Southcentral Foundation, “The Trust for Health Excellence’s Better Health Initiative”
  • Looking “in” on the patient Looking “out” to the Health Care Environment
  • Looking “in” on the patient Looking “out” to the Health Care Environment Patient-centered medical homes (PCMH) – Not necessarily a “place” rather a central point from which assistance is provided to navigate the fragmented healthcare system Source: Oliver Wyman, Tom Main & Adrian Slywotzky
  • HEALTH PLAN CO-PAYs All Metallic plans on Public Health Insurance Marketplace & SHOP Exchanges DIRECT PAYMENT FOR E–CONSULTS  RANGE - $50 - $100  NO CLAIMS ADJUDICATION NECESSARY  CONVENIENCE OF ACCESS DRIVES PATIENT ENGAGEMENT  STEERS ADOPTION OF ELECTRONIC PATIENT PORTAL USAGE
  • EHRs Capture the discrete data electronically
  • Clinical Integration within IDNs Clinical Registry Data – Reviewed by Physicians providing the care ICD-9/10 & HCPCS from PMS and CPT/DRG Diagnosis from EHR EHRs Capture the discrete data electronically
  • Clinical Integration within IDNs Clinical Registry Data – Reviewed by Physicians providing the care ICD-9/10 & HCPCS from PMS and CPT/DRG Diagnosis from EHR Payer incentives to providers PQRS, Tiered Narrow Networks, Core Measures, ACOs EHRs Capture the discrete data electronically
  • The year 2048 33 33 33
  • The year 2048 33 33 33
  • The year 2048 33 33 33
  • Financial Savings Potential from Medication Adherence Chronic Condition Savings Per Patient per Year Congestive Heart Failure – CHF $7,823 Hypertension $3,908 Diabetes $3,756 High cholesterol $1,258 Source: CVS Caremark Research Partnership: Advancing Adherence & the Science of Pharmacy Care, Volume 2. Page 5 www.cvscaremarkfyi.com/sites/all/themes/cvs_theme/11-CVS-346-NPC_2012_compendium_final_web.pdf
  • Financial Savings Potential from Medication Adherence Chronic Condition Savings Per Patient per Year Congestive Heart Failure – CHF $7,823 Hypertension $3,908 Diabetes $3,756 High cholesterol $1,258 Source: CVS Caremark Research Partnership: Advancing Adherence & the Science of Pharmacy Care, Volume 2. Page 5 www.cvscaremarkfyi.com/sites/all/themes/cvs_theme/11-CVS-346-NPC_2012_compendium_final_web.pdf We need to leverage New Methods to PROMOTE HEALTHY HABITS!
  • “As the rats were learning, the reinforcement signal goes away, because you really don’t need it” Source: Dr. Ann Graybiel, MIT: Brain rhythms are key to learning New study from MIT neuroscientists finds that brain waves shift frequency as a new task becomes routine. Anne Trafton, MIT News Office, November 27, 2011
  • “As the rats were learning, the reinforcement signal goes away, because you really don’t need it” Source: Dr. Ann Graybiel, MIT: Brain rhythms are key to learning New study from MIT neuroscientists finds that brain waves shift frequency as a new task becomes routine. Anne Trafton, MIT News Office, November 27, 2011
  • Back out of Driveway
  • Drive to WorkBack out of Driveway
  • Drive to WorkBack out of Driveway Get to the Office
  • Realize you CAN’T REMEMBER the actual trip itself. As if in a Trance Drive to WorkBack out of Driveway Get to the Office
  • Process of Emotional Eating Can be a similar experience Realize you CAN’T REMEMBER the actual trip itself. As if in a Trance Drive to WorkBack out of Driveway Get to the Office
  • Cues Routines Rewards
  • Cues Routines Rewards AUTOPILOT
  • You better cut the pizza in four pieces because I’m not hungry enough to eat six. ~ Yogi Berra
  • $90,000 $41,000 $236 0 COST BREAK DOWN Average Annual Healthcare Spend in USA Per Person Heart Disease Diabetes Arthritis Asthma Source: National Institute of Health Care Management 2012 C O S T D R I V E R S
  • Access to Discrete (Patient Identified) Claims Data of population 1. ASO (Self-Funded Plan) or ACO (Entitlement or Commercial) 2. HIE from Practice Management Systems or Patient Billing Systems
  • Access to Discrete (Patient Identified) Claims Data of population 1. ASO (Self-Funded Plan) or ACO (Entitlement or Commercial) 2. HIE from Practice Management Systems or Patient Billing Systems Clinical Data – HIE from EHR or Clinical Integration Registry
  • Access to Discrete (Patient Identified) Claims Data of population 1. ASO (Self-Funded Plan) or ACO (Entitlement or Commercial) 2. HIE from Practice Management Systems or Patient Billing Systems Medication Data 1. Claims from ASO (Self-Funded Plan) or ACO (Entitlement or Commercial) 2. HIE from E-Prescribe system, E-Prescribe transaction hub (Surescripts) or directly from the PBM (if permitted by plan design and regulations) Clinical Data – HIE from EHR or Clinical Integration Registry
  • OLAP/SQL
  • OLAP/SQL
  • RISK SCORES Episode Risk Groups (ERGs) Episode Treatment Groups (ETGs) Hierarchical Condition Categories (HCC) OLAP/SQL
  • Advanced Predictive Model Determines “Risk Index” and Care Method Risk/Cost Profile: Total Population Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Risk/Cost Profile: Total Population Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Core Chronic Disease Management • Program delivering disease-customized content for disease-identified members • Standards of care and HEDIS Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Core Chronic Disease Management • Program delivering disease-customized content for disease-identified members • Standards of care and HEDIS Lifestyle Coach • Members prioritized by Risk Profile severity • Coaching based on modifying lifestyle risks that lead to increasing medical costs Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Core Chronic Disease Management • Program delivering disease-customized content for disease-identified members • Standards of care and HEDIS Lifestyle Coach • Members prioritized by Risk Profile severity • Coaching based on modifying lifestyle risks that lead to increasing medical costs Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Self-Management (Web and Multi-Modal) • Customized via members’ participation in the WBA, a Well-Being Plan organizes web content to serve the individual needs of the member self- managing healthy behavior improvement Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Core Chronic Disease Management • Program delivering disease-customized content for disease-identified members • Standards of care and HEDIS Lifestyle Coach • Members prioritized by Risk Profile severity • Coaching based on modifying lifestyle risks that lead to increasing medical costs Surveillance • Some members may not participate in the WBA • Via routine Claims Analysis and Predictive Model runs, 100% of the population is continuously evaluated & re-prioritized for program intervention Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Self-Management (Web and Multi-Modal) • Customized via members’ participation in the WBA, a Well-Being Plan organizes web content to serve the individual needs of the member self- managing healthy behavior improvement Costs
  • Advanced Predictive Model Determines “Risk Index” and Care Method Clinicians (PCP and Mid-Level) • Targeted at very top ranked members who benefit from intensive intervention model by MD team Core Chronic Disease Management • Program delivering disease-customized content for disease-identified members • Standards of care and HEDIS Lifestyle Coach • Members prioritized by Risk Profile severity • Coaching based on modifying lifestyle risks that lead to increasing medical costs Surveillance • Some members may not participate in the WBA • Via routine Claims Analysis and Predictive Model runs, 100% of the population is continuously evaluated & re-prioritized for program intervention Nurse Coach • Team-based model targeted at high- opportunity members Risk/Cost Profile: Total Population Self-Management (Web and Multi-Modal) • Customized via members’ participation in the WBA, a Well-Being Plan organizes web content to serve the individual needs of the member self- managing healthy behavior improvement Costs Readmission Avoidance Program • Event-based rather than cohort-based • The Discharge event and the member’s relative risk index are considered in evaluating the need for an outreach call • Members’ transition from Hospital to aftercare are coordinated to reduce readmission likelihood
  • Source: Marc Prensky - Digital Natives, Digital Immigrants published in 2001 Digital Natives born after 1996 Digital Immigrants born prior to 1996 Digital Nomads Mobile Bohemian – Mobos
  • Source: Microsoft
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Appointment Scheduling and Coordination  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Appointment Scheduling and Coordination  Escalation for unacknowledged messages or results  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Appointment Scheduling and Coordination  Escalation for unacknowledged messages or results  Nimble architecture – SOA based on Web Services  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Appointment Scheduling and Coordination  Escalation for unacknowledged messages or results  Nimble architecture – SOA based on Web Services  Middleware adapter and business logic for outreach via text or IVR.  Contact Information Directory 
  •  Case & Disease Management – Workflow Mngt & Assessments  Longitudinal Care Plans & Plan Adherence  Open Access platform for multitude of Caregivers  Appointment Scheduling and Coordination  Escalation for unacknowledged messages or results  Nimble architecture – SOA based on Web Services  Middleware adapter and business logic for outreach via text or IVR.  Contact Information Directory  HIE protocol capabilities – HL7, SNOMED, LOINC
  • Web Email Text/Mobil e Mail Social Communities IVRTelephonic Face-to- Face Home Care
  • Web Email Text/Mobil e Mail Social Communities IVRTelephonic Face-to- Face Home Care
  • Web Email Text/Mobil e Mail Social Communities IVRTelephonic Face-to- Face Home Care
  • Web Email Text/Mobil e Mail Social Communities IVRTelephonic Face-to- Face Home Care
  • Source: Oliver Wyman, The Volume-To-Value Revolution, Rebuilding the DNA of Health from the Patient in, Tom Main & Adrian Slywotzky, 2012
  • Qualcomm Life 2net Sensors
  • Qualcomm Life 2net Sensors Implantable In Vivo Glucose Monitor
  • Qualcomm Life 2net Sensors Implantable In Vivo Glucose Monitor Wearable fitbi t
  • Qualcomm Life 2net Sensors Implantable In Vivo Glucose Monitor Wearable fitbi t Behavior Tracking Glowcaps
  • In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013
  • www.monitoringcare.co m TeleHealth Integrators In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013
  • www.monitoringcare.co m TeleHealth Integrators In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013 Telemedicine Solutions
  • www.monitoringcare.co m TeleHealth Integrators Data Aggregators- MDI In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013 Telemedicine Solutions
  • Case Studies www.monitoringcare.co m TeleHealth Integrators Data Aggregators- MDI In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013 Telemedicine Solutions
  • Case Studies www.monitoringcare.co m TeleHealth Integrators Data Aggregators- MDI In Apple App Store 18,564 Medical Apps 22,817 Healthcare & Fitness Apps Source: http://148apps.biz/app-store-metrics, May 1, 2013 Telemedicine Solutions Trade Shows
  • Incent Personal Accountability Source: Healthways Use Holistic Analysis to isolate ROOT of Unhealthy Habits
  • Recruit Individual into Social Support Networks to foster positive peer awareness Realign the FINANCIAL RI$K shared among Employers, Payers and Employees toward a common set of achievable goals
  • CARROTS Commitment Contract - $$ gain for meeting period goals, $$ at risk for not meeting goals Daily Challenges – Organized daily or weekly challenges among work peers (Biggest Loser), Pedometer competitions STICKS $500-$1000/yr Surcharge for non-participation in Biometric Screening Tobacco usage – ranging around $2000/yr surcharge to Non-Hiring policies of tobacco users
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  • ALL COACHING IS: IS TAKING A PLAYER WHERE HE CAN’T TAKE HIMSELF ~ Bill McCartney College Football Coach
  • Reach me at LinkedIn: John Squeo