Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Capturing Your Hidden Value: Using Newly Released Government Benchmark Data to Select Value Programs and Negotiate Risk Arrangements

723 views

Published on

RowdMap, Inc. joined the Rothman Institute at the Medical Group Management Association (MGMA) 2015 National Conference on using government benchmark data to identify and capture hidden value for physicians entering value-based risk arrangements.

Joshua Rosenthal, PhD, Chief Scientific Officer and Co-Founder at RowdMap, Inc., joined Mike West, Chief Executive Officer at the Rothman Institute to jointly speak on how doctors can use newly released government data to identify and capture hidden value to succeed in value based risk arrangements. The presentation entitled, “Capturing Your Hidden Value: Using Newly Released Government Benchmark Data to Select Value Programs and Negotiate Risk Arrangements,” was delivered at the Medical Group Management Association (MGMA) 2015 National Conference.

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Capturing Your Hidden Value: Using Newly Released Government Benchmark Data to Select Value Programs and Negotiate Risk Arrangements

  1. 1. 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.
  2. 2. 2 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. What RowdMap Does Risk-Readiness SM and You Rothman Institute as Best Practice
  3. 3. 3 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. What RowdMap Does Risk-Readiness SM and You Rothman Institute as Best Practice
  4. 4. 4 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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. WHAT WE DO It’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. Effectsof Health Care Payment Models on Physician Practice in the United States, May 2015.
  5. 5. 5 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. Featured Nationally US CTO on RowdMap: “Visionary Genius” WHO WE ARE Founders & Team
  6. 6. 6 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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Melanie Rosenthal – Chief Executive Officer Co-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 Officer Co-Founder & CTO @ Sprigley [acquired by Eliza Corporation, 2008]; Platform Architect @ Eliza [Majority Equity Investment Parthenon Capital, 2011], Health Dialog, Pricewaterhouse Coopers; Ernst & Young; Standards Committees Joshua Rosenthal, PhD – Chief Scientific Officer Co-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 HCTTF Speaker/Guest Lecturer/Guest @ Harvard, Johns Hopkins, MIT , SXSW, HDI, RWJ, AF4Q, NPR (with US CTO and HHS CTO) Henriette Coetzer, MD – Chief Clinical Risk Officer Clinical Transformation, NHS (National Health Service, United Kingdom); Global Medical Director, Towers Watson; Senior Medical Director and Clinical Analytics, BUPA and Health Dialog; Product Development, Healthways; Practicing Physician; Patent Holder Kimberly Spalding, CPA – Chief Financial Officer Co-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 Strategists Cornell, Xavier; Cincinnati Children’s Hospital, Optimity Advisors, Presence Health; Skydiver, Travel Connoisseur WHO WE ARE Founders & Team Industry Leading Advisory Board
  7. 7. WHO WE ARE Where It’s Worked 7 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. RowdMap Success Stories • Increaseda 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 competitivemetro by 20% • Launched high-end conciergeplan that broke member price sensitivity and generatedsignificant profit, doubling original membership goal • Launched a purpose-built plan for a curatedprovider network • Increaseda plan’s Star scores by a full point through provider-centric growth • Designed product strategy and corresponding benefits for a major metro area that lead to plan’s first profitable product portfolio in three years • Aligned a plan’s sales and networkteam strategyaround providers • Tripled a plan’s original goal of contracting with targetedproviders (and in some cases, out of exclusivity arrangements) • Shifted a plan’s majority of membershipfrom PPO to HMO, doubling original goal • Moved a plan’s membershipin targetproviders from 2% to 30% in target providers in 12 months • Articulatedclear data-drivenMA strategy for board-levelpresentations that resultedin additional investments • Developed comprehensive strategyfor governmentaffairs that created an advantageous environment for plan and members Where we’ve done it…
  8. 8. 8 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. What You Get with RowdMap Technology and Professional Service Enterprise Platform License License covers entire enterprise across all functional units and all (reasonable) users and usage RowdMap U Online Learning Center One of a kind web-based resource with tips, tricks, tutorials and functionally- oriented resources to help users understand, and interpret the information Benchmarks Drill Downs and Profiles Payer Profiles, Provider Profiles, Market and Geographic Profiles Including Social Determinants and Health Behaviors On-site Analytic Workshops RowdMap prepares an analysis across functional areas and presents data, interpretation and recommendati ons Auto- Generated Reporting Self-serve dashboards and reporting with tagging and sharing that export as PDF or PPT Enrichment Client Data RowdMap 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 & Support Provider Performance Profiles and Risk- Readiness Analysis New Payment Model Opportunity Analysis Reimbursement Opportunity and Payer Profile Analysis Policy and Regulatory Analysis
  9. 9. 9 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. 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 DO Risk-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
  10. 10. 10 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. Plan from prevalence & physician supply Population Report Card Population Health Report Population Supply and Demand Report Population Over-coding / Under-coding Report Match your practicepatternsto the right arrangements Risk-ReadinessSM Profile Risk-ReadinessSM Landscape Risk-ReadinessSM Value Chain Referral and Leakage Analysis Risk-ReadinessSM Arrangement Match-Maker Risk-ReadinessSM Medical Economics Report Negotiateusing government benchmarks Payer Report Card Payer Profit Driver Report Payer Product Impact Report Payer - Provider Negotiation Report Payer - Provider Network Adequacy and Optimization Report
  11. 11. 11 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. What RowdMap Does Risk-Readiness SM and You Rothman Institute as Best Practice
  12. 12. 12 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 disclosureof 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 Rid of 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 Managementat 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
  13. 13. 13 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. 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 Intensity Practice Pattern Maximizing Pay for Value
  14. 14. 14 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. Magnitude of Problem Means Darwinian Approach 30% 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
  15. 15. 15 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 disclosureof 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 Data Particularly 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.
  16. 16. Here’s why these benchmarks are so powerful 16 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. Government benchmark data serves as the common language necessary 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.)
  17. 17. 17 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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. HospitalMarketshare by Major Clinical Categories ProviderGroupMarketshare by Major Clinical Categories PhysicianMarketshare by Major Clinical Categories MSSP Candidate Circulatory Respiratory Unnecessary Spend in Miami By 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
  18. 18. 18 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 disclosureof 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
  19. 19. 19 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. 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 Medicare Eligibles / MA Enrolled Exchange Subsidy Eligibles / Exchange Enrolled Medicaid Beneficiary 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.
  20. 20. 20 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 disclosureof 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
  21. 21. 21 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 disclosureof 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
  22. 22. 22 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 disclosureof 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
  23. 23. 23 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 disclosureof 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 Report Westchester County, NY
  24. 24. 24 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. Decreased Cost Average Increased Cost LessEfficient 1 2 3 4 5 MoreEfficient Miami Dade, Florida Risk-ReadinessSM 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.
  25. 25. 25 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. Know Exactly How Much Value You Create for Whoever Owns the Risk in Any Arrangement Primary Care Docs Specialist Post 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
  26. 26. 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 disclosureof 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
  27. 27. 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 Care Often Do Not Get Credit
  28. 28. 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 Care Often 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
  29. 29. 29 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 disclosureof 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 on path to risk Match appropriate risk arrangements based on provider practice patterns and Population characteristics within a geography
  30. 30. 30 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 disclosureof 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
  31. 31. 31 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. What RowdMap Does Risk-Readiness SM and You Rothman Institute as Best Practice Mike West, CEO
  32. 32. 32 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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Philadelphia, PA Orthopedic Surgeons Only Group Risk-Readiness SM Report Rothman Institute Best 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.
  33. 33. 33 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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Philadelphia, PA Orthopedic Surgeons Only Group Risk-Readiness SM Report Rothman Institute Best 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?

×