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Network as Strategic Advantage: Curating a Risk-Ready Network to Succeed in a Value-Based Market

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RowdMap, Inc. soke with HCSC Health Care Service Corporation at America’s Health Insurance Plans, 2015 National Conferences on Medicare and Medicaid and Dual Eligibles Summit on using government benchmark data to create a risk-ready network to succeed in value-based market.

Bryant Hutson, Senior Client Strategist at RowdMap, Inc., and David Goodson, Vice President, Enterprise Medicare, Health Care Service Corporation, spoke together on how health plans can use newly released government data to create a risk-ready network to succeed in value-based markets. The presentation entitled, “Network as Strategic Advantage: Curating a Risk-Ready Network to Succeed in a Value-Based Market” was delivered at the America’s Health Insurance Plans (AHIP), 2015 National Conferences on Medicare and Medicaid and Dual Eligibles Summit.

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Network as Strategic Advantage: Curating a Risk-Ready Network to Succeed in a Value-Based Market

  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 BCBS 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 BCBS 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. What RowdMap Does Risk-Readiness SM and You BCBS as Best Practice
  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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Risk-Readiness℠ looks at a different category of spending 30 Cents of Every Dollar You Spend Goes to 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
  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. 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
  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. 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.
  13. 13. Here’s why these benchmarks are so powerful 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. 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.)
  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. Where are populations, and how healthy are they? Who are Risk-Ready SM providers? How do we match the right providers to the right risk arrangements and manage variation to contain costs? How do we design products, clinical programs, and networks around risk? WHAT WE DO Risk-Readiness SM in Four Questions
  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. UNDERSTAND POPULATIONS What type of populations? Diabetes Prevalence PCP Density Income Obesity Depression Demand vs. Supply Sick and underserved Westchester, NY Allocate providers and care management resources around condition-specific population needs by zip. Focus contracting on PCPs and/or locate retail clinics, RVs and health fairs based on chronic needs.
  16. 16. 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. UNDERSTAND GEOGRAPHY What’s Going on 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 What drives profitability in your geography? Consider: CMS reimbursement and risk models, population cost share thresholds, clinical performance outcomes, population health behaviors, network performance, product eligibles & penetration.
  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. Risk-Readiness SM Practice Profiles Orange County, CA Regional Benchmarks Identify highly efficient, Risk-Ready practices to profitably grow into. Improve profitability of lower performing practices with large panel sizes through modified arrangements or performance improvement plans.
  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. Risk-Readiness SM Physician Profiles PCPs Identify low cost, highly efficient physicians and make them your stars. Grow into them. Make them the featured doctor in marketing collateral. Regional Benchmarks Louisville, KY
  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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Risk-Readiness SM Hospital Profiles California Regional Benchmarks Use benefit designs and network designs to send members to the highest performing hospitals within your geography. EOL Hosp Days: Which hospitals have 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 imagingcompared to their peers?
  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 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 MANAGE VARIATION Quantify No Value Spending by Provider $ PMPY per Specialty & Efficiency Score Networks can be optimized by excluding specific doctors or shifting members/patients within a network. Tactic 1: 'Manage' the red dot doctors Tactic 2: Create curated networks with varsity providers.
  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 disclosure of any of its contents without the prior written consent of the Company, is prohibited. MANAGE VARIATION Provider Value Chains 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.
  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 disclosure of any of its contents without the prior written consent of the Company, is prohibited. MANAGE ACROSS FUNCTIONS Product, Growth & Clinical After developing an overall Risk-Readiness SM Strategy, plans use RowdMap to… Manage product portfolios and design benefits Identify areas for growth and expansion Design and manage clinical programs
  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. 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? WHAT WOULD YOU DO IF YOU KNEW who will win and who will lose in value based arrangements
  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. What RowdMap Does Risk-Readiness SM and You BCBS as Best Practice David Goodson Vice President, Enterprise Medicare at Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas
  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 disclosureof any of its contents without the prior written consent of the Company, is prohibited. Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas Best Practice at Risk-Readiness SM Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas Using data to answer all four major questions including: 1 - Where are the populations and how healthy are they? 2 - Who are Risk-Ready Providers? 3 - How do we match the right providers to the right arrangements and manage variation to contain costs? 4 - How do we design products, clinical programs and growth strategies around risk?
  26. 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. Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas Best Practice at Risk-Readiness SM Questions for David Goodson, Vice President Enterprise Medicare, at Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas 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?

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