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CREATING	A	VIRTUOUS	CYCLE:	
DESIGNING	NETWORKS	
TO	MITIGATE	NO-VALUE	CARE	FROM	FEE	FOR	SERVICE	
AND	CREATE	VALUE-BASED	WIN...
OWNING	RISK	IS	TOUGH,	BUT	IT’S	WHERE	THE	ACTION’S	AT
Once	upon	a	time	plans	had	large	group	commercial	populations	with	ye...
CREATING	A	VIRTUOUS	CYCLE:	
DESIGNING	NETWORKS	
TO	MITIGATE	NO-VALUE	CARE	FROM	FEE	FOR	SERVICE	
AND	CREATE	VALUE-BASED	WIN...
4
No-Value	
Care	(30%)
Necessary	Utilization
(70%)
Care	That	Doesn’t	Produce	Better	Outcomes
$850	Billion	Unnecessary	Spen...
No-Value	Care:
CMS	Is	Paying	on	It
2016 World Economic Forum
Annual Meeting in Switzerland
On	track	to	
sunset	50%	of	FFS
No-Value	Care:
Success	Defined	by	It
“During its first year, the Pioneer ACO program was associated with modest reductions...
“Millions of people are receiving drugs that aren’t
helping them, operations that aren’t going to make
them better, and sc...
"It's	no	secret	that	patients	often	undergo	unnecessary	procedures	that	can	
be	dangerous	and	costly."	Through	our	collabo...
No-Value	Care:
Doc.s Focus	on	It
Over	70	Specialty	Societies
No-Value	Care:
Market	Demands	It
“The	Task	Force	recommends	that	CMS	consider	
the	addition	of	such	information	into	
base...
No-Value	Care:
Decades	of	Research	on	It
The	estimated	30%	of	medical	expense	
that	goes	to	no-value	care.		
Unnecessary	s...
No-Value	Care:
CMS	Opens	Data	on	It
Medicare	DocGraph	
Referral	file	
(Patient	flows	between	
PCPS,	specialists,	hospitals...
No-Value	Care:
Innovation	Founded	on	It
RowdMap	has	no-value	care	and	
population	health	benchmarks for…
every	physician
e...
No-Value	Care:
Market	Adopting	It
Health	plans	and	providers	in	48	states	and	the	District	of	Columbia
use	RowdMap	and	HHS...
No-Value	Care:
Positive	Disruption:
A	Virtuous	Cycle	
Told
‘ya
Market	
Incentive	
Open	
Data
Positive	Disruption	in	
a	Com...
Virtuous	Cycles
Three	Examples
Ali	Khan,	Medical	Officer	at	CareMore,	an	Anthem	Company
Steve	Ondra,	Chief	Medical	Officer...
Virtuous	Cycles
Three	Examples
Ali	Khan,	Medical	Officer	at	CareMore,	an	Anthem	Company
Steve	Ondra,	Chief	Medical	Officer...
Virtuous	Cycles
Three	Examples
Ali	Khan,	Medical	Officer	at	CareMore,	an	Anthem	Company
Steve	Ondra,	Chief	Medical	Officer...
Virtuous	Cycles
Three	Examples
Ali	Khan,	Medical	Officer	at	CareMore,	an	Anthem	Company
Steve	Ondra,	Chief	Medical	Officer...
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RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using cms benchmark data

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Session at Health Datapalooza on designing and curating a pay for value ready network with Value Proposition: Designing and Curating a Pay-for-Value Ready Network
 
Joshua Rosenthal, PhD Co-Founder and Chief Scientific Officer at RowdMap, Inc.; Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services; Ali Khan, Medical Officer at CareMore, an Anthem Company; Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC.

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RowdMap Health Datapalooza Creating a Virtual Cycle: designing networks to mitigate no-value care from fee for service and create value-based wins for both payers and providers using cms benchmark data

  1. 1. CREATING A VIRTUOUS CYCLE: DESIGNING NETWORKS TO MITIGATE NO-VALUE CARE FROM FEE FOR SERVICE AND CREATE VALUE-BASED WINS FOR BOTH PAYERS AND PROVIDERS USING CMS BENCHMARK DATA Positive Disruption
  2. 2. OWNING RISK IS TOUGH, BUT IT’S WHERE THE ACTION’S AT Once upon a time plans had large group commercial populations with years of consistency and providers simply delivered services for a fee. But government programs like Medicare Advantage, Marketplace / Exchange and Medicaid, have populations changing every year, or even every month and providers managing a population's health over time. Changing populations and dynamic payment models may make it tough to predict and achieve member outcomes in a financially sustainable way precisely when providers are getting in the game to take on risk. Public health data are providing solid case studies of achieving member health and happiness with sustainable financial models for all players in this new game. If you are managing risk, considering taking on risk, or investing in or providing products or services to anyone bearing risk, camp out in these sessions to learn how to use public data and internal resources to: § Effectively leverage analytic approaches to manage risk § Accurately assess risks and project costs § Effectively align providers and incentivize care delivery
  3. 3. CREATING A VIRTUOUS CYCLE: DESIGNING NETWORKS TO MITIGATE NO-VALUE CARE FROM FEE FOR SERVICE AND CREATE VALUE-BASED WINS FOR BOTH PAYERS AND PROVIDERS USING CMS BENCHMARK DATA Value Proposition: Designing and Curating a Pay-for-Value Ready Network Moderator: Joshua Rosenthal, Co-Founder and Chief Scientific Officer at RowdMap, Inc. Panelists: Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services; Ali Khan, Medical Officer at CareMore, an Anthem Company; Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC
  4. 4. 4 No-Value Care (30%) Necessary Utilization (70%) Care That Doesn’t Produce Better Outcomes $850 Billion Unnecessary Spend in 2014 (Institute of Medicine) No-Value Care: .30 / Each $ Is Wasted “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
  5. 5. No-Value Care: CMS Is Paying on It 2016 World Economic Forum Annual Meeting in Switzerland On track to sunset 50% of FFS
  6. 6. No-Value Care: Success Defined by It “During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations providing more low- value care. Accountable care organization–like risk contracts may be able to discourage use of low-value services even without specifying services to target.”
  7. 7. “Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.” Dr. Atul Gawande, Professor, Department of Health Policy and Management at the Harvard School of Public Health & the Department of Surgery at Harvard Medical School. No-Value Care: Media Is Reporting on It
  8. 8. "It's no secret that patients often undergo unnecessary procedures that can be dangerous and costly." Through our collaboration with RowdMap, we are providing patients with meaningful information about these no- or low-value treatments, allowing them to make better, more informed decisions about their doctors, hospitals and medical care.” No-Value Care: Consumers Demand It
  9. 9. No-Value Care: Doc.s Focus on It Over 70 Specialty Societies
  10. 10. No-Value Care: Market Demands It “The Task Force recommends that CMS consider the addition of such information into baseline/benchmark calculations.” “We suggest that entities structuring care management programs… monitor the extent to which the participating providers are delivering low- or no-value care.”
  11. 11. No-Value Care: Decades of Research on It The estimated 30% of medical expense that goes to no-value care. Unnecessary spending drives billing in a fee-for-serve economic model, but success in pay-for-value comes from managing and mitigating these pockets of variation. Variation: Unwarranted or Unexplained? Every physician has a unique fingerprint Economic Drill Down: Example Utilization Review and Actuarial Unit Cost Analysis against Care Intensity Curve across Total Basket of Care Variation across geographies and within practices across physicians. “Physician-Level Practice Variation: Who You See Is What You Get” Brian Powers, Sachin Jain, David Cutler, & Ziad Obermeyer Health Affairs, 09.23.15 Definitions, research and geocoding by Hospital Referral Regional available via the Dartmouth Atlas for Unwarranted Variation: www.dartmouthatlas.org NB: Unwarranted variation refers to practice patterns, which hold up across populations but pricing variation may also be unwarranted and marked fluctuates across insurance product and lines and geography. “The Price Ain’t Right.” Cooper, Craig, Gaynor and Van Reenen, 2015.
  12. 12. No-Value Care: CMS Opens Data on It 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. Affordable Care Act data to determine Risk-Readiness of Providers / Networks
  13. 13. No-Value Care: Innovation Founded on It RowdMap has no-value care and population health benchmarks for… every physician every hospital every zip code …in the United States. What if you knew which providers would drive your success?
  14. 14. No-Value Care: Market Adopting It Health plans and providers in 48 states and the District of Columbia use RowdMap and HHS data to reduce the delivery of no-value care. The clients RowdMap serves collectively cover the lives of more than 100 million Americans. Here’s where HHS Data is being used to move from FFS to Value Base Arrangements (not ‘pilot’ or ‘innovation’ programs) but active operational programs. Clients using HHS data include National, Regional & Boutique Payers in Marketplace/Exchange, MA, Medicaid, Commercial and Government Programs as well as Providers including PCP & Specialty Groups, CINs & Systems, ACOs, Bundles & other CMMI Program Participants.
  15. 15. No-Value Care: Positive Disruption: A Virtuous Cycle Told ‘ya Market Incentive Open Data Positive Disruption in a Complex System Data Liberators
  16. 16. Virtuous Cycles Three Examples Ali Khan, Medical Officer at CareMore, an Anthem Company Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services
  17. 17. Virtuous Cycles Three Examples Ali Khan, Medical Officer at CareMore, an Anthem Company Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services
  18. 18. Virtuous Cycles Three Examples Ali Khan, Medical Officer at CareMore, an Anthem Company Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services
  19. 19. Virtuous Cycles Three Examples Ali Khan, Medical Officer at CareMore, an Anthem Company Steve Ondra, Chief Medical Officer at Health Care Service Corporation (Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma and Texas) and Senior Policy Advisor for Health Affairs at the Department of Veterans Affairs in Washington, DC Jonathan Blum, Executive Vice President at CareFirst Blue Cross BlueShield and Former Principal Deputy Administrator at Centers for Medicare and Medicaid Services

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